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ANiESTHESIA,  HOSPITALISM, 
HEMAPHRODITISM, 


AND  A 


SCHOLAB  OF  GONVILLE  AND  CAITT8  COLLEGE,  CAMBEIDGE. 


NEW  YORK: 

D.  APPLETON  AND  COMPANY, 

549  & 551  BKOADWAY. 

18'72. 


*> 


I • 


' A 


• Strict 


.'  •'  V- . , j.-t-. 


-,v,  IjJ 


3 


A y 

' r/  ^ ^ 


PEEFACE. 


It  would  have  been  presumptuous  in  me,  not  being  a 
medical  man,  to  attempt  to  edit  this  volume  of  my 
father’s  works,  had  it  not  been  evident  that  a careful 
selection  and  arrangement  of  material  was  nearly  all 
that  was  required  of  me. 

The  Papers  on  Ansesthesia  contain  most  of  my  father’s 
writings  on  the  subject,  those  papers  and  parts  of  j)apers 
only  being  omitted  which  would  have  been  repetitions 
of  others  which  appear  in  the  volume.  Many  of  the 
articles  were  published  in  his  Obstetric  Memoirs  and 
Contributions,  edited  in  1855-6  by  Drs.  Priestley  and 
Storer.  Others  have  been  written  since.  I have  tried  to 
give  them  in  a logical  rather  than  in  a chronological  se- 
- quence,  putting,  when  necessary,  at  the  head  of  each  the 
y date  of  its  original  production.  Although  a consecutive 
c work,  written  in  later  years  on  the  subject  by  my  father, 
would  have  given  more  prominence  to  some  points  and 
^ less  to  others  than  these  papers  do,  yet  it  is  hoped  that 
^ they  will  be  found  at  least  to  touch  upon  most  of  the 
^ topics  that  would  have  come  under  discussion  in  a more 
complete  treatise  on  the  subject. 

801898 


VI 


PREFACE. 


The  Papers  on  Hospitalism  are  similarly  arranged, 
and  contain  all  that  their  author  lived  to  write  in  vindi- 
cation of  his  opinions  on  the  subject. 

Eeferences  to  the  journals,  etc.,  in  which  such  of  the 
Papers  as  have  already  been  in  print  originally  appeared, 
will  be  found  at  the  end. 

W.  G.  SIMPSON. 


Edinburgh,  October  1871, 


CONTENTS 


ANJESTHESIA. 

PART  I— HISTORY  OF  ANESTHESIA. 

Chap.  I.  Ancient  History  of  Ancestliesia  .... 

Chap.  II.  Modern  History  of  Anaesthesia  ..... 
Chap.  III.  Modern  History  of  Anaesthesia  {continued) 

1.  Tendency  to  Confusion  from  the  Discovery  of  Chloroform 

rapidly  following  that  of  Sulphuric  Ether 

2.  Earliest  Anaesthetic  Operations  in  America,  and  their 

Connection  with  Hartford  and  Boston  . 

3.  Etherisation,  or  Anaesthesia,  in  Midwifery 

4.  Alleged  Neglect  of  American  Claims  in  writing  a Sketch 

of  the  History  of  Anaesthetics  .... 

PAKT  II.— DEFENCES  OF  ANESTHESIA. 

Chap.  I.  Answer  to  the  Eeligious  Objections  advanced  against  the 
employment  of  Anaesthetic  Agents  in  Midwifery  and 
Surgery  ....... 

Chap.  II.  Same  Subject  continued,  in  a Letter  to  Dr.  Protheroe  Smith 
of  London  - ...... 

Chap.  III.  Mere  Opinions  and  Prejudgments  not  sufficient  to  settle  the 
Question  of  the  Propriety  or  Impropriety  of  Anaesthetic 
Agents  : Illustrated  from  the  History  of  Yaccination 
Chap.  IV.  The  Prevention  of  Pain  in  Surgical  Operations  alleged  to  be 
Unnecessary  and  Improper  .... 

Chap.  V.  Pain  in  Operations  from  a Patient’s  Point  of  View  . 

Chap.  VI.  Does  Anaesthesia  increase  or  decrease  the  Mortality  attend- 
ant upon  Surgical  Operations  ? . 


PACK 

1 

12 

18 

23 

25 

31 

35 


42 

56 


65 

75 

86 

93 


viii 


CONTENTS. 


PAGE 


Chap.  VII. 
Chap.  VIII. 

Chap.  IX. 
Chap.  X. 
Chap.  XI. 


Answer  to  Objections  to  Anaesthesia  in  Midwifery 
Answer  to  the  Objections  to  Ansesthesia  in  Midwifery,  adduced 
by  Professor  Meigs  of  Philadelphia 
Peply  to  other  Minor  Objections  to  Anaesthesia  in  Midwifery^ 
Alleged  Difficulties  in  the  Superinduction  of  Anaesthesia 
Eemarks  on  the  occasional  Fatal  Eesult  of  the  Administration 
of  Chloroform,  with  cases  of  Sudden  Death  during  Surgical 
Operations  without  Anaesthetics  .... 


108 

117 

138 

141 


143 


PAET  III.— THE  NATUEE  AND  POWEE  OF  VAEIOUS 
ANESTHETIC  AGENTS. 

Chap.  I.  General  Considerations  .....  154 

Chap.  H.  Chloroform  . . . . . . .157 

Chap.  HI.  Chloride  of  Hydrocarbon,  Nitrate  of  Ethyle,  Benzin,  Aldehyde, 

and  Bisulphuret  of  Carbon  . . . .165 

Chap.  IV.  Anaesthetic  and  sedative  properties  of  Bichloride  of  Carbon, 

or  Chlorocarbon  . . . . . .170 


PAET  IV.— APPLICATIONS  OF  ANESTHESIA  IN  SUEGEEY 
AND  MEDICINE. 

Chap.  I.  Conditions  for  ensuring  successful  Anaesthesia  in  Surgery  ; cau- 
tions, etc.  . . . . . . .174 

Chap,  1 1.  Cases  illustrative  of  the  Use  and  Effects  of  Chloroform  in 

Surgery  .......  183 

Chap.  HI.  Chloroform  in  Infantile  Convulsions,  and  other  Spasmodic 

Diseases,  in  Pneumonia,  and  in  Peritonitis  . . .186 


PAET  V.— APPLICATIONS  OF  ANESTHESIA  IN  MIDWIFEEY. 


Chap.  I.  On  the  Inhalation  of  Sulphuric  Ether  in  the  Practice  of  Mid- 
wifery . . . . . . .192 

Chap.  1 1.  ^Mode  of  exhibiting  Chloroform  in  Midwifery  ; dose,  etc.  . 201 

Chap.  HI.  Cases  illustrative  of  the  Use  and  Effects  of  Chloroform  in  Mid- 

Avifcry  .......  207 

Chap.  IV.  Eeport  of  the  Eesults  of  Anaesthesia  from  different  Obstetric 

Hospitals  and  Practitioners  ....  214 

Chap.  V.  Eesults  of  the  Practice  of  Anaesthesia  in  Midwifery  . . 245 


CONTENTS. 


PART  VL— LOCAL  ANAESTHESIA. 


Chap.  I.  Preliminary  Notice  regarding  Artificial  Local  Amiestlicsia 
Chap.  II.  On  the  production  of  Local  Anaesthesia  in  the  Lower  Animals . 
Chap.  III.  On  the  production  of  Local  Anaesthesia  in  the  Human  Subject 
Chap.  IV.  Practical  Application  of  Chloroform  as  a Topical  Anaesthetic 
to  Mucous  and  Cutaneous  Surfaces 
Chap.  V.  Carbonic  Acid  Gas  as  a Local  Anaesthetic 


Chap.  VI.  Parts  and  Surfaces  to  which  Carbonic  Acid  may  be  applied 

1 to  5.  Vagina  and  Uterus  ; Rectum  and  lower  end  of  In- 
testinal Canal ; the  Interior  of  the  Stomach  ; the  Surface 
of  the  Tongue  ; the  ulcerated  Surface  of  the  Skin,  etc. 

6.  The  Mucous  Surface  of  the  Eye  .... 

7.  The  Mucous  Surface  of  the  Bladder 

8.  The  Mucous  Surface  of  the  Trachea  and  Lungs 

9.  To  External  Wounds  and  Burns  .... 


HOSPITALISM. 


Chap. 


Chap. 


I.  Country  Amputation  Statistics 


H. 


1.  Preliminary  Remarks  ..... 

2.  Mortality  of  the  Major  Amputations  of  the  Limbs  in 

Private  Country  and  Provincial  Practice 
( 2098  Country  Amiiutations 

Statistics  of  •]  ‘ [•  . . 

( 2089  Hospital  Amputations  j 

1.  Some  minor  points  pertaining  to  the  Collection  of  Ampu- 
tations ....... 


2.  Causes  of  Death  in  the  Fatal  Cases  of  Amputation 

3.  Classes  of  Patients  on  whom  the  Two  Thousand  Amputa- 

tions were  performed,  and  the  general  Character  of  their 
Habitations  ...... 


4.  Severity  of  some  of  the  Cases  that  recovered 

5.  Opinions  as  to  Amputations,  etc.,  succeeding  better  in 

Private  Country  than  in  Public  Hospital  Practice 

6.  Evidence  of  Increased  Success  in  Amputations  from 

Increased  Experience  ..... 

7.  On  the  Results  of  Limb-Amputations  in  Private  Practice 

in  other  Countries  ..... 

8.  Mortality  of  the  Four  Major  Amputations  in  Large  and 

IMetropolitan  Hospitals  ..... 

9.  The  Proportionate  Death-rate  and  the  excess  of  Mortality 

of  Limb-Amputations  in  large  and  Metropolitan  Hos- 
pitals as  compared  with  Country  Practice 


ix 


PAGE 

253 

256 

260 

269 

276 

285 

285 

285 

285 

287 

287 


289 

289 

292 

305 

305 

310 

313 

317 

322 

324 

327 

329 

338 


X CONTENTS. 

Chap.  III.  Some  Propositions  on  Hospitalism,  based  on  Statistics  of 
Country  and  Hospital  Amputations 
Chap.  IV.  Some  Propositions  on  Hospitalism  {continued) . 

Chap.  V.  Statistics  of  3077  Provincial  Hospital  Amputations 

1.  Mortality  from  Limb- Amputations  in  tlie  Provincial 

Hospitals  of  Great  Britain  .... 

2.  The  Mortality  of  Limb-Amputations  as  regulated  by  the 

size  of  Hospitals,  and  the  degree  in  which  Patients  are 
aggregated  or  isolated  ..... 
Chap.  VI.  How  our  Present  Hospitals  could  be  most  easily  altered,  in 
order  to  render  them  more  Salubrious  , • • 

HERMAPHBODITmi, 

Varieties  of  Hermaphroditism  ...••• 
Spurious  Hermaphroditism  ...... 

True  Hermaphroditism  ...... 

Hermaphroditism  as  manifested  in  the  General  Conformation  of  the 
Body  and  in  the  Secondary  Sexual  Characters 
Kemarks  on  the  Nature  of  True  Hermaphroditic  Malformations 
Causes  of  Hermaphroditic  Malformations  .... 

Bibliography  ........ 


PROPOSAL  TO  STAMP  OUT  SMALL- POX  AND 
OTHER  CONTAGIOUS  DISEASES  . 


PAGK 

340 

382 

390 

390 


398 

400 


407 

410 

432 

479 

500 

532 

540 


*543 


PAET  1. 

HISTOEY  OF  ANESTHESIA, 


CHAPTER  I. 

ANCIENT  HISTORY  OF  ANAESTHESIA. 

The  idea  of  saving  by  some  artificial  means  the  human  body  from 
the  pains  and  tortures  inflicted  by  the  knife  of  the  surgeon  is  by  no 
means  a thought  first  broached  or  first  acted  upon  in  recent  times. 
For  the  production  of  amesthesia  a variety  of  measures  had  been 
suggested  and  employed  long  before  the  introduction  of  sulphuric 
ether  and  chloroform. 

We  may  consider  these  means  under  several  heads,  according  as 
the  insensibility  to  pain  was  to  be  effected  either — 

1.  By  the  inhalation  of  gases  or  vapours. 

2.  By  mechanical  means. 

3.  By  the  internal  administration  of  drugs. 

1.  Ancesthesia  hy  the  inhalation  of  vapours  or  gases. — Under  this 
head  I may  mention  the  following  suggestions: — In  1795  Dr. 
Pearson  proposed  the  inhalation  of  sulphuric  ether  (and  he  appears 
to  have  been  the  first  to  do  so),  but  apparently  only  for  the  purpose 
of  relieving  the  cough  in  asthma,  etc.,  and  not  for  producing  general 
anaesthesia.  In  1816  Nysten  introduced  a special  apparatus  for  its 
inhalation.  In  1800  Sir  H.  Davy  recommended  the  employment  of 
nitrous  oxide  gas  for  the  relief  of  pain  in  the  extraction  of  teeth  and 
other  minor  surgical  operations,  and  he  also  described  the  effects  it 
had  on  himself  when  he  inhaled  it  to  relieve  local  pain.  Thus,  he 
says : — “ The  power  of  the  immediate  operation  of  the  gas  in  re- 
moving intense  physical  pain,  I had  a very  good  opportunity  of 
ascertaining.  In  cutting  one  of  the  unlucky  teeth  called  dentes 
sapientise,  I experienced  an  extensive  inflammation  of  the  gum, 
accompanied  with  great  pain,  which  equally  destroyed  the  power  of 


2 


HISTORY  OF  ANiFSTHESIA. 


repose  and  of  consistent  action.  On  the  day  when  the  inflammation 
was  most  troublesome  I breathed  three  large  doses  of  nitrous  oxide. 
The  pain  always  diminished  after  the  first  four  or  five  inspirations, 
the  thrilling  came  on  as  usual,  and  uneasiness  was  for  a few  minutes 
SAvallowed  up  in  pleasure.  As  the  former  state  of  mind,  however, 
returned,  the  state  of  organ  returned  with  it ; and  I once  imagined 
that  the  pain  was  more  severe  after  the  experiment  than  before.”  ^ 

Sir  H.  Davy  recommended  its  employment  in  surgery  in  the 
following  Avords “ As  nitrous  oxide  in  its  extensive  operation 
appears  capable  of  destroying  physical  pain,  it  may  probably  be 
used  with  advantage  during  surgical  operations  in  which  no  great 
effusion  of  blood  takes  place. 

Dr.  Hickman  also,  in  1828,  suggested  the  inhalation  of  carbonic 
acid,  as  a means  of  producing  insensibility  in  surgical  operations. 

There  were  other  agents  used  for  this  purpose  in  more  ancient 
times,  which,  although  they  produced  their  effects  by  inhalation  of 
their  vapours,  I may  describe  more  conveniently  under  the  third  of 
these  divisions. 

2.  Ancesthesia  hy  mechanical  means. — In  1784  Dr.  Moore  proposed 
to  bring  about  local  anaesthesia  of  limbs  during  surgical  operations, 
by  compressing  the  nerves  supplying  them.  He  tried  this  method  in 
a case  in  Dr.  Hunter’s  practice,  applying  a tourniquet  for  an  hour 
before  the  operation,  to  compress  the  nerves,  with,  however,  only 
partial  success.  Malgaigne  also  tried  the  tourniquet,  but  Avith  no 
better  result,  for  he  found  that  the  instruments  used  for  the  com- 
pression of  the  nerves  themselves  produced  considerable  pain.  This 
mode  had  been  suggested,  I may  observe,  by  Ambrose  Pare  long 
before  Moore’s  time.  It  was  supposed  at  one  time  that  compression 
of  the  carotid  arteries,  and  consequent  diminution  of  the  supply  of 
blood  to  the  brain,  Avould  be  successful  in  j^roducing  anaesthesia;  and 
this  plan  was  even  put  into  practice  by  Yalverdi,  Hoffman,  and 
Others,  in  the  sixteenth  and  seventeenth  centuries.  Morgagni 
mentions  that  this  practice  AA^as  folloAved  in  the  dissecting-room  on 
animals  to  induce  anaesthesia,  and  he  also  suggests  its  use  in  the 
human  subject.  There  is  not  the  least  doubt  that  it  Avill  induce 
stupor  or  coma,  and  that,  moreover,  Avith  extreme  rapidity.  This 
is  too  frequently  proved  in  cases  of  garrotting,  of  Avhich  an  instance 
is  on  record  Avhere  stupor  Avas  successfully  produced,  and  robbery 
committed,  betAveen  the  time  of  the  victim  ringing  his  door-bell  and 
the  servant  answering  the  summons.  This  method  was  again  lately 

^ Chemical  and  Fhilosoi^hical  Experiments,  p.  464.  ® Idem,  p.  566- 


ANCIENT  HISTOEY. 


3 


proposed  for  employment  in  surgery  some  years  ago  by  Professor 
Fleming. 

3.  Ancesthesia  by  internal  administration  of  drugs. — In  various 
authors,  both  of  ancient  and  modern  times,  we  read  of  drugs  used 
to  induce  anaesthesia,  but  we  can  seldom  make  out  exactly  what  were 
the  substances  employed. 

In  the  Medical  Gazette,  vol.  xli.  p.  515,  Dr.  Sylvester  quotes  a 
passage  from  a German  work  by  Meissner,  called  Skizzen,  published 
in  1782,  to  the  following  effect : — • 

“Augustus,.  King  of  Poland  and  Elector  of  Saxony,  suffered 
from  a wound  in  his  foot,  which  threatened  to  mortify.  The  Court 
medical  men  were  opposed  to  the  operation  of  amputation,  but 
during  sleep,  induced  by  a certain  potion  surreptitiously  admini- 
stered, his  favourite  surgeon,  Weiss,  a pupil  of  Petit  of  Paris,  cut 
off  the  decaying  parts.  The  royal  patient  was  disturbed  by  the 
proceeding,  and  inquired  what  was  being  done,  but  on  receiving  a 
soothing  answer  he  again  fell  asleep,  and  did  not  discover  till  the 
following  morning,  after  his  usual  examination,  that  the  operation 
of  amputation  had  really  been  performed.” 

Opium  has  been  suggested  at  various  times,  but  the  dose  whicli 
would  be  required  to  produce  anaesthesia  would  be  so  large  that  no 
one  could  safely  administer  it.  We  know,  however,  that  formerly 
two  substances  were  held  in  great  repute  by  patients  about  to  undergo 
surgical  operations,  and  also  by  criminals  condemned  to  suffer 
torture.  Those  drugs  were  Indian  hemp  {Cannabis  sativa,  var.  Indica) 
and  mandragora  {Atropa  mandragora,  but  now  called  Mandragora 
officinalis).  It  will  be  interesting,  if  not  advantageous,  to  consider 
the  history  of  each  of  these  separately,  and  somewhat  in  detail. 

Indian  Hemp. — Sir  Joseph  Banks  alludes  to  the  preparation  and 
use  of  this  drug  in  various  parts  of  the  east  from  Morocco  to  China, 
in  which  couhtries  it  goes  under  the  names  of  bang,  churrus,  and 
gunjah.  He  mentions  that,  when  any  preparation  of  this  plant 
is  swallowed,  the  mind  is  immediately  filled  by  a delicious  succession 
of  pleasant  ideas,  which  banish  all  cares  and  produce  a perfect 
indifference  to  pain.  This  state  is,  however,  soon  followed  by  sleep. 
The  drug  is  more  especially  used  by  criminals  doomed  to  suffer 
torture,  and  it  seems  to  be  what  is  taken  by  the  Hindoo  Suttee 
to  give  her  powers  of  endurance.  Some  years  ago  an  old  Chinese 
manuscript  was  laid  before  the  French  Academy  by  M.  Julien,  in 
which  the  use  of  Indian  hemp  for  annulling  the  pain  in  cauterisation 
and  surgical  operations  is  mentioned  as  having  been  had  recourse  to 


4 


HISTORY  OF  ANAESTHESIA. 


by  a practitioner  by  name  Hoa-tho,  as  early  as  the  third  century, 
that  is  about  1500  years  ago. 

In  this  manuscript,  which  is  called  Koukin-i-ting,  we  find  the 
following  passage  : — “ He  (Hoa-tho)  gave  to  the  patient  a prepara- 
tion of  hemp  (Ma-yo),  and  at  the  end  of  some  instants  he  became  as 
insensible  as  if  he  had  been  drunk,  or  deprived  of  life  and  a little 
faither  on  it  is  remarked  that,  “ after  a certain  number  of  days  the 
patient  found  himself  re-established,  without  having  experienced 
the  slightest  pain  during  the  operation.” 

We  can  trace  the  use  of  Indian  hemp  still  farther  back,  for 
some  divines  maintain  that  the  draught  offered  to  our  Saviour  on 
the  cross  was  some  preparation  of  Indian  hemp.^ 

A preparation  of  the  same  drug  is  probably  referred  to  by  the 
prophet  Amos,  700  years  before  Christ,  as  the  “wine  of  the  con- 
demned.”^ 

The  effect  of  the  inhalation  of  the  vapour  of  burning  hemp  is 
mentioned  by  Herodotus,  who  also  tells  us  of  its  use  by  the  Mas- 
sagetse  and  by  the  Scythians  to  produce  excitement.  Thus,  talking 
of  the  Massagetje,  he  says  “ that  they  have  discovered  other  trees 
that  produce  fruit  of  a peculiar  kind,  which  the  inhabitants,  when 
they  meet  together  in  companies,  and  have  lit  a fire,  throw  on  the 
fire  as  they  sit  round  in  a circle  ; and  that,  by  inhaling  the  fumes 
of  the  burning  fruit  that  has  been  thrown  on,  they  become  intoxi- 
cated by  the  odour,  just  as  the  Greeks  do  by  wine  ; and  that  the 
more  fruit  is  thrown  on  the  more  intoxicated  they  become,  until 
they  rise  up  to  dance,  and  betake  themselves  to  singing.”^ 

Again,  when  describing  another  tribe  of  the  Scythians,  he 
informs  us  that  “ they  have  a sort  of  hemp  growing  in  this  country, 
very  like  flax,  except  in  thickness  and  height ; in  this  respect  the 
hemp  is  far  superior  and  a little  farther  on  he  informs  us  that, 
“ when  therefore  the  Scythians  have  taken  some  seed  of  this  hemp, 
they  creep  under  the  cloths,  and  then  put  the  seed  on  the  red-hot 
stones ; but  this  being  put  on,  smokes,  and  produces  such  a steam 
that  no  Grecian  vapour-bath  would  surpass  it.  The  Scythians, 
transported  Avith  the  vapour,  shout  aloud  ; and  this  serves  them 
instead  of  washing,  for  they  never  bathe  the  body  in  water.” 

Homer  also  gives  us  an  account  of  the  effect  on  Ulysses  and  his 
companions  of  drinking  some  preparation,  which  he  called  Nepen- 
the, and  the  phenomena  he  describes  are  so  like  those  produced 

^ Mark  xv.  36.  ^ Amos  ii.  8.  ^ Cary’s  Herodotus,  i.  202. 

^ Cary’s  Herodotus^  iv.  74. 


ANCIENT  HISTOEY. 


5 


by  hemp  that  we  may  conclude  it  was  of  this  substance  they  made 
use.  He  tells  us  that  the  Jove-descended  Helen  planned  other 
things,  and  that  “ she  straightway  cast  a drug  into  the  wine,  from 
whence  they  were  drinking,  that  frees  men  from  grief  and  from 
anger,  and  causes  oblivion  of  all  ills.  Whoever  should  drink 
down  this,  when  it  is  mixed  in  a cup,  would  not  shed  a tear  down 
his  cheeks  for  a whole  day,  not  even  if  both  his  mother  and  father 
should  die,  nor  if  they  should  slay  with  the  steel  a brother  or  a 
beloved  son  before  him,  and  he  should  behold  it  with  his  eyes. 
Such  cunning  and  excellent  drugs  the  daughter  of  Jove  possessed, 
which  Polydamnia,  the  wife  of  Thon,  gave  her,  an  Egyptian.”  ^ 

Pliny  also  mentions  this  drug  (Indian  hemp)  in  his  Natural 
History^  but  he  does  not  speak  of  its  inhalation,  but  merely  remarks 
that  it  was  used  for  making  ropes. 

Mandragora. — This  plant  was  most  extensively  used  by  Hugo  of 
Lucca  in  the  twelfth  century,  and  the  preparation  employed  by  him 
is  described  to  us  by  his  son  and  successor,  Theodoric,  who  died 
in  1298,  under  the  name  of  the  Spongia  somnifera,  that  is  the 
somniferous  ball,  or  sponge,  or  apple.  In  his  Chirurgial,  which  he 
published  on  entering  the  church,  and  in  which  he  made  known 
most  of  the  chemical  preparations  and  rules  of  the  art  of  surgery 
which  had  been  followed  by  Hugo,  who  had,  however,  kept  them 
all  secret,  we  find  that  this  somniferous  sponge  was  prepared 
according  to  the  following  prescription  : — “ Take  of  opium,  of  the 
juice  of  the  unripe  mulberry,  of  hyoscyamus,  of  the  juice  of  hem- 
lock, of  the  juice  of  the  leaves  of  mandragora,  of  the  juice  of  the 
woody  ivy,  of  the  juice  of  the  forest  mulberry,  of  the  seeds  of 
lettuce,  of  the  seeds  of  the  dock  which  has  'large  round  apples,  and 
of  the  water-hemlock — each  an  ounce  ; mix  all  these  in  a brazen 
vessel,  and  then  place  in  it  a new  sponge  ; let  the  wdiole  boil,  as 
long  as  the  sun  lasts  on  the  dog-days,  until  the  sponge  consumes  it 
all,  and  it  has  boiled  away  in  it.”"^ 

He  then  goes  on  to  describe  the  way  in  which  this  sponge  is  to 
be  used — “ As  oft  as  there  shall  be  need  of  it,  place  this  sponge  in 
hot  wafer  for  an  hour,  and  let  it  be  applied  to  the  nostrils  of  him 
who  is  to  be  operated  on,  until  he  has  fallen  asleep,  and  so  let  the 
surgery  be  performed.” 

He  then  tells  us  how  to  rouse  the  patient  after  the  operation  is 
over.  “ This  being  finished,  in  order  to  awaken  him,  apply  another 

^ Homer  by  Buckley,  Odysseij,  iv.  219.  2 jfist.  Nat.  xix.  36. 

^ Chirurgial,  iv.  8. 


6 


HISTORY  OF  ANESTHESIA. 


sponge,  dipped  in  vinegar,  frequently  to  the  nose,  or  throw  the 
juice  of  the  root  of  fenugrek  into  the  nostrils  ; shortly  he  awakens.” 

This  preparation  was,  however,  gradually  abandoned,  perhaps 
from  its  occasionally  causing,  as  we  are  told  by  Aretseus,  convul- 
sions and  coma,  and  in  some  cases  even  death.  In  the  works  of 
M.  Chamappe,  published  in  1534,  we  learn  that  this  somniferous 
sponge  was  still  in  use  in  his  time ; but  it  must  have  been  very 
nearly  abandoned  then,  for  towards  the  close  of  that  century  Par^ 
tells  us  that  it  was  a practice  “ used  formerly  ” by  operators. 

But  we  find  many  allusions  made  to  the  anaesthetic  effect  of 
mandragora  by  ancient  authors,  among  which  I may  mention  the 
following  : — 

Dioscorides  refers  to  the  effects  of  the  drug  in  several  passages 
thus : — 

“ Some  persons  boil  the  root  in  wine  down  to  a third  part,  and 
preserve  the  decoction,  of  which  they  administer  a cyathus  in  want 
of  sleep  and  severe  pains  of  any  part,  and  also  before  operations 
with  the  knife  or  the  actual  cautery,  that  they  may  not  be  felt.”^ 

“ There  is  prepared  also,  besides  the  decoction,  a wine  from  the 
bark  of  the  root,  three  minte  being  thrown  into  a cask  of  sweet 
wine  ; and  of  this  three  cyathi  are  given  to  those  who  are  to  be 
cut  or  cauterised  as  aforesaid ; for,  being  thrown  into  a deep  sleep, 
they  do  not  perceive  pain.”^ 

Again,  when  speaking  of  another  kind  of  mandragora,  which  he 
calls  morion,  he  says — 

“ They  relate  that  a drachm  of  it  being  taken  as  a draught,  or 
eaten  in  a cake  or  other  food,  causes  infatuation,  and  takes  away 
the  use  of  the  reason.  The  person  sleeps  without  sense,  in  the 
attitude  in  which  he  ate  it,  for  three  or  four  hours  afterwards. 
Medical  men  also  use  it  when  they  have  to  resort  to  cutting  or 
burning.”* 

Pliny,  speaking  of  mandragora,  says,  “ It  has  the  power  of  causing 
sleep  in  those  who  take  it.  The  dose  is  half  a cyathus.  It  is  taken 
against  serpents,  and  before  cuttings  and  puncturings,  lest  they 
be  felt.  For  these  purposes  it  is  sufficient  for  some  persons  to  have 
sought  sleep  from  the  smell.”  * Apuleius,  after  telling  us  that  there 
are  two  plants  of  mandragora,  one  male  and  the  other  female,  which 
have  the  power  of  even  causing  death,  remarks — 

“ If  any  one  eat  it  he  will  immediately  die,  unless  he  be  treated 
with  butter  and  honey,  and  vomit  quickly.  Further,  if  any  one  is 

^ Dioscorides,  iv.  7C.  ^ Ibid.  " Ibid.  Hist.  Nat.  xxv.  94. 


ANCIENT  HISTORY. 


7 


to  have  a member  mutilated,  burned,  or  sawn,  let  him  drink  half 
an  ounce  with  wine,  and  let  him  sleep  till  the  member  is  cut  away 
without  any  pain  or  sensation.”  ‘ 

Aurelianus  talks  of  the  “ wandering  of  the  mind  ” v/hich  occurs 
“ in  those  who  have  drunk  mandragora  or  altercus.”  ^ Baptista 
Porta,  in  his  Natural  Magic^  which  was  published  in  1G08,  speaks 
of  the  account  given  of  the  drug  by  Dioscorides,  who  “ says  that 
those  men  who  have  drunk  mandragora  will  sleep,  all  their  senses 
being  entirely  lost,  for  three  or  four  hours  after  they  have  taken 
it,  and  that  medical  men  use  this  plant  when  they  wish  to  cut  or 
burn  anybody.”  A little  further  on  he  informs  us  how  to  prepare 
a sleeping  apple  “ with  opium,  mandragora,  juice  of  the  water-hem- 
lock, seeds  of  hyoscyamus,  and  to  these  musk  is  added  to  impart  an 
agreeable  odour,  collected  into  a mass  as  large  as  one  can  hold  in 
his  fist ; this,  he  adds,  “ when  repeatedly  smelt,  softens  down 
and  binds  the  eyes  in  sleep.”  Subsequently  he  states  that  “ it  is 
possible  to  extract  from  several  soporific  plants  a quintessence, 
which  is  to  be  shut  up  in  well  covered  leaden  vessels,  lest  the  drug 
should  evaporate.  When  it  is  to  be  used,  the  lid  is  to  be  removed 
and  the  medicament  held  to  the  nostrils,  when  its  vapour  will  be 
drawn  in  by  the  breath  and  attack  the  citadel  of  the  senses,  so  that 
the  patient  will  be  sunk  in  the  deepest  sleep,  not  to  be  shook  off 
without  much  labour.  After  sleep  no  headache  remains,  nor  any  sus- 
j^icion  of  art.  Such  things,”  he  adds,  “ are  clear  to  a wise  physician, 
to  a wicked  one  obscure.” 

Columella  also  mentions  mandragora,  but  does  not  say  much 
about  its  use.*  Demosthenes  mentions  anaesthesia.®  The  effects  of 
mandragora  are  also  alluded  to  by  Galen,  who  concludes  by  remark- 
ing that  those  who  are  thus  affected  quickly  lose  the  sense  and 
motion  of  the  whole  body.^ 

Innumerable  passages  occur  among  more  modern  authors,  from 
which  we  learn  that  deep  sleep  was  brought  on  by  anaesthetising 
draughts,  but  in  most  of  those  which  I shall  bring  forward  their 
nature  and  compositions  are  not  told  us. 

In  Le  Proces  Criminel  by  Claude  Lebrun  de  la  Eochette,  we 
have  the  following  remark  as  to  the  employment  of  such  drugs  by 
criminals  about  to  suffer  torture  : — “ As  to  their  artifices  not  to  feel 
the  pain  of  the  rack,  I saw  in  the  first  year  of  my  reception  at  the 

^ 3fedicaminibus  Herharum,  cap.  129.  ^ De  morhis  amtis,  I.  4. 

* Naturol  3Iagic,  viii.  i.  ^ Book  x.  17.  ® Demosthenes,  hy  Eeiske,  564-12. 

® Galen,  vii.  207. 


67 


8 


HISTORY  OF  AMSTHESIA. 


bar  of  Beaujolais,  which  was  in  the  year  1588,  that  one  of  four 
thieves,  who  were  prisoners, — the  chief  named  Grand  Francois,  a 
man  of  gigantic  stature,  was  put  to  the  rack,  fell  asleep,  and  the  toes 
were  torn  from  both  his  feet,  without  his  manifesting  any  signs  of 
pain.  One  of  his  companions  observed  that  he  had  eaten  soap 
which  stupified  the  nerves.  The  remedy  to  the  artifice  is  to  give 
wine,  which  being  brought  and  drunk,  he  then  said  he  was  dead, 
and  without  any  further  torture,  freely  confessed  an  infinite  number 
of  murders  and  robberies,  to  atone  for  which  he  and  his  companions 
were  broken  in  the  wheel  by  sentence  of  Master  Thomassot,  Provost 
of  the  Mareschals  in  Beaujolais.”^ 

Shakespeare,  in  the  tragedy  of  “ Romeo  and  Juliet,”  says — 

“Within  the  infant  rind  of  this  weak  flower 
Poison  hath  residence,  and  med’cine  power  : 

For  this,  being  smelt,  with  that  part  cheers  each  part ; 

Being  tasted,  slays  all  senses  with  the  heart.”  ^ 

And  a little  farther  on  he  says — 

“ Take  thou  this  phial,  being  then  in  bed. 

And  this  distilled  liquor  drink  thou  off : 

When,  presently,  through  all  thy  veins  shall  run 
A cold  and  drowsy  humour  ; for  no  pulse 
Shall  keep  his  native  progress,  but  surcease. 

No  warmth,  no  breath,  shall  testify  thou  liv’st ; 

The  roses  in  thy  lips  and  cheeks  shall  fade 
To  paly  ashes  ; thy  eyes’  windows  fall. 

Like  death,  when  he  shuts  up  the  day  of  life  ; 

Each  part  deprived  of  supple  government. 

Shall  stiff,  and  stark,  and  cold,  appear  like  death  ; 

And  in  this  borrow’d  likeness  of  shrunk  death 
Thou  shalt  continue  two-and-forty  hours. 

And  then  awake  as  from  a pleasant  sleep.”  ^ 

So  also  in  “ Cymbeline  ” we  find  the  following  lines  : — 

“ Those  she  has 

Will  stupify  and  dull  the  sense  awhile  : 

Which  first,  perchance,  she’ll  prove  on  cats  and  dogs  ; 

Then  afterward  up  higher  ; but  there  is 
No  danger  in  what  show  of  death  it  makes, 

IMore  than  the  locking  up  the  spirits  a time, 

To  be  more  fresh,  reviving.” 

In  tlie  works  of  Dio  Bartas  the  following  passage  occurs  : — 

“ As  the  surgeon  who  desires  to  remove  some  incurable  limb, 
before  he  approaches  the  knife  to  the  diseased  pact,  sends  the  patient 

1 Book  ii.  p.  144. 

2 Act  iv.  Scene  1. 


" Act  ii.  Scene  3. 
^ Act  i.  Scene  6. 


ANCIENT  HISTORY. 


9 


to  sleep  by  an  iced  beverage,  then  without  any  pain,  guided  by  use 
and  art,  to  save  the  entire  man,  cuts  off  a part.” 

Boccaccio,  in  \\\^  Decameron,  published  in  1461,  says — 

“ It  occurred  that  the  surgeon  had  in  hand  a patient,  one  of 
whose  limbs  was  diseased,  and  knowing  whence  the  evil  proceeded, 
told  the  man’s  friends  that  if  a rotten  bone  in  the  leg  was  not  re- 
moved, it  would  be  necessary  to  cut  off  the  limb  or  the  patient  would 
die ; but  by  removing  the  bone  it  might  be  cured  ; however,  he 
would  not  undertake  the  operation  unless  the  patient  were  given  up 
as  dead.  To  this  the  family  agreed.  The  surgeon,  thinking  that  if 
the  patient  were  not  sent  to  sleep  he  would  be  unable  to  bear  the 
pain,  and  would  not  permit  the  operation,  deferred  performing  it 
till  the  following  evening  ; and  distilled  in  the  morning  a water  of 
a certain  composition  of  his  own,  which,  when  the  patient  had 
drunk  of  it,  would  keep  him  asleep  as  long  as  the  operation  might 
last.”^ 

Jacques  Yver  of  Poitou  remarks,  in  his  “ Printemps  ” — 

“ And  if  I am  so  delighted  (pardon  me  if  I cannot  lie)  that,  like 
a patient  set  to  sleep  with  mandragora,  for  the  purpose  of  cutting 
off  a limb,  I do  not  feel  my  disease.”  ^ 

The  following  extracts  are  from  Guillaume  Bouchet’s  work  en- 
titled Les  Berks,  published  in  1554  : — “ Others  have  written  that  if 
you  take  some  marble  from  Grand  Cairo,  called  by  the  ancients 
memphitis,  reduce  it  to  powder,  and  apply  it  as  a liniment  with 
vinegar,  and  lubricate  with  it  the  part  to  be  cut  off  or  cauterised, 
the  patient  will  not  feel  much  pain  or  inconvenience  ” (p.  39).  “ But 

if  they  have  taken  certain  beverages,  replied  some  one,  what  can 
the  judge  do  1 For  Albert  affirms  that  the  stone  denominated  mem- 
phitis, when  pulverised  and  mixed  with  water  and  butter,  and  taken 
by  the  malefactor  who  is  to  be  tortured,  causes  him  to  feel  no  pain. 
Cardow  also  says  that  a person  anointed  with  opium,  celandine, 
saffron,  and  the  marrow  and  fat  of  a man,  with  oil  of  lizards,  or  if 
he  drinks  wine  in  which  the  seeds  of  portulsea  marina  has  been 
steeped  for  a weeke,  that  will  prevent  him  from  feeling  any  pain, 
and  consequently  from  confessing  anything.  However,  according 
to  some,  De  Marsilis,  who  believed  in  these  charms,  and  employed 
counter-charms,  is  w^orthy  of  ridicule  only  ; they  say  it  is  proved 
that  all  the  recipe  for  persons  tortured,  in  order  that  they  may  feel 
no  pain,  is  nothing  more  than  soap  dissolved  in  clean  water,  which 

^ See  Journal  of  Practical  Medicine  and  Surgery,  1861.  Eng.  Edn.  p.  139. 

2 Idem.  2 Idem,  pp.  139  and  140. 


10 


HISTORY  OF  ANESTHESIA. 


is  given  to  them  to  drink,  and  has  the  property  of  lulling  the  senses. 
I should  deem  it  still  better,  says  another — if  Pliny  tells  the  truth — 
that  they  gave  in  wine  an  herb  named  archimenides,  to  criminals  sus- 
pected of  any  offence  ; which,  being  drunk,  sets  to  sleep,  and  in 
their  sleep  the  confession  of  the  fact  may  be  drawn  from  them  much 
better  than  by  any  other  kind  of  torture  and  rack”  (pp.  63  and 
6 4).  “ And  I think,  added  he,  they  could  give  me  a potion 
which  would  prevent  me  from  hearing  the  thunder,  since  the  Turks 
administer  to  those  they  are  about  to  castrate,  cauterise,  or  ampu- 
tate, a composition  which  makes  them  sleep  so  soundly  that  they 
suffer  no  pain  ” (p.  1 1 3). 

I shall  close  my  remarks  on  the  ancient  history  of  anaesthetics 
in  surgery,  by  quoting  the  following  passage  from  Middleton’s  tragedy 
of  “ Women,  beware  Women,”  in  which  he  alludes  to  the  practice  of 
setting  patients  to  sleep  before  performing  operations  on  them  : — 

“I’ll  imitate  the  pities  of  old  surgeons 
To  this  lost  limb — who,  ere  they  show  their  art, 

Cast  one  asleep,  then  cut  the  diseased  part.” 

The  History  of  Ancesthetics  in  Midwifery. — The  ancients  appear  also 
to  have  attempted  to  relieve  the  pain  attendant  upon  parturition  by 
anaesthetising  agents,  as  we  may  learn  from  various  Greek  writers. 
Such  a practice  is  mentioned  by  Plautus  in  his  Ophelion,  and  I may 
also  quote  the  following  passage.  Theocritus  says — 

“ For  then  the  daughter  of  Antigone,  weighed  down  with  throes, 
called  out  for  Lucina,  the  friend  of  women  in  travail,  and  she  with 
kind  favour  stood  by  her,  and  in  sooth  poured  down  her  whole  limbs 
an  insensibility  to  pain,  and  so  a lively  boy,  like  to  his  father,  was 
born.”*  That  author  calls  the  insensibility  to  pain  nodynia  (vojdvvta), 
which  is  a better  word  than  anaesthesia  ; and  I have  often  regretted 
not  adopting  it,  rather  than  the  latter.  The  composition  of  the 
various  narcotic  draughts  in  use  for  this  purpose  is  not,  however, 
recorded. 

In  Jocelyn’s  Life  of  St.  Kentigern  or  St.  Mungo  of  Glasgow,- 
which  is  contained  in  the  Vitce  Antiquce  Sanctorum  Scot  ice,  we  read 
that  Thenu,  the  saint’s  mother,  was  impregnated  without  her 
knowledge,  under  the  influence  of  some  anaesthetic  potion.  In 
co*nsequence  of  this  she  was  condemned  to  be  cast  down  from  tlie 
top  of  a high  hill  called  Dunpelder,  which  was  accordingly  done, 
but,  wonderful  to  say,  she  received  no  hurt.  Not  satisfied  with  this 
apparently  divine  interference,  her  judges  then  sentenced  her  to  be 


^ Idyl  xviii. 


2 Cap.  i.  et.  seq. 


ANCIENT  HISTORY. 


11- 


cast  adrift  in  a small  boat  on  the  Firth  of  Forth,  but  she  was  safely 
floated  across  to  Fife,  and  her  boat  stranded  near  a place  called 
Collotious  (Culross),  where  she  was  received  and  taken  Ciire  of  by 
St.  Servanus,  who  taught  near  there,  and  in  due  time  she  was  safely 
delivered  of  a son,  the  afterwards  famous  St.  Kentigern,  the  first 
Christian  in  Scotland. 

In  the  trials  of  the  sixteenth  century  we  find  many  cases  in 
which  witches  were  prosecuted  for  attempting  to  abolish  the  pains 
of  labour  by  charms  and  other  means.  One  method  that  was 
practised  was  to  hold  a sword  before  the  patient,  who  was  directed 
to  look  at  it  steadily,  in  the  same  way  that  Latina  is  said  to  have 
held  a palm  branch,  and  brought  forth  Apollo  without  suffering ; an 
attempt  at  mesmerism  in  reality.  Another  way  employed  was  to 
hang  the  husband  up  in  the  next  room  by  his  feet,  till  the  labour 
was  accomplished.  Such  a plan  would  not  meet  with  much  appro- 
bation and  encouragement  now.  The  celebrated  case  of  the  Countess 
de  St.  Geran  is  another  instance  of  narcotic  draughts  being  adminis- 
tered to  alleviate  the  pains  of  labour.  After  she  had  been  nine 
hours  in  labour,  the  midwife  gave  her  a mixture  which  kept  her  in 
an  anaesthetic  state  till  the  following  morning,  by  wdiich  time  she 
was  safely  delivered  of  a son. 


12 


HISTOKY  OF  ANESTHESIA. 


CHAPTER  IL 

MODERN  HISTORY  OF  ANESTHESIA.’ 

Edinburgh,  Januanj  1870. 

Dear  Sir — There  has  been  sent  to  me  from  America  a Chicago 
newspaper,  containing  a letter  of  yours  which  is  alleged  to  have 
been  published  in  a late  number  of  the  Boston  Medical  and  Surgical 
Journal.  In  this  letter  you  speak  of  the  bestowal  upon  me,  some 
months  ago,  by  my  fellow-townsmen,  of  the  rank  of  an  honorary 
burgess  of  Edinburgh  ; and  you  comment,  in  terms  of  bitterness, 
upon  the  subject,  and  upon  what  I said — or  rather  upon  what  I did 
not  say — on  that  occasion.  I feel  assured  that  if  you  or  any  one 
else  had  felt  as  nervous  and  timid  as  I did  on  rising  to  address  the 

^ Letter  to  Dr.  Jacob  Bigelow,  Boston,  in  answer  to  the  following. — Dr. 
Bigelow  says — “ But  many  persons  will  think  it  a mistake  in  the  adoption  of  a 
foreign  discovery  to  ignore  the  source  whence  he  derived  it.  Sir  James  Simpson, 
in  a long  and  eloquent  reply,  while  he  complacently  accepts  the  crown  of  bor- 
rowed plumes  thus  tendered  to  him,  makes  not  the  slightest  allusion  to  the 
country  from  which  they  were  plucked,  in  which  country  anaesthetic  inhalation, 
with  more  agents  than  one,  was  established,  vindicated,  and  successfully  prac- 
tised, long  before  it  was  heard  of  in  Edinburgh  or  any  other  part  of  Europe. 

“It  is  not  wonderful  that,  in  the  designs  of  Providence,  medicinal  agents 
should  exist  capable  of  averting  pain  by  the  suspension  of  sensibility ; but  the 
wonder  is  that,  after  mankind  had  borne  pain  ever  since  the  creation  of  their 
race,  any  person  should  be  found  of  sufficient  courage  and  strength  of  conviction 
to  put  through  the  untried  and  formidable  experiments  necessary  to  decide 
whether  life  could  continue  under  the  inhalation  of  a scarcely  respirable  vapour, 
carried  to  such  an  extent  as  to  destroy  sensibility  and  produce  apparent  death. 
That  man  was  not  Sir  James  Y.  Simpson.  The  history  of  anaesthetic  inhalation 
is  Avell  known.  It  began  in  this  country,  and  was  first  used  in  the  extraction  of 
teeth,  and  afterwards  in  capital  operations  at  the  Mass.  General  Hospital,  and  in 
obstetrical  practice.  The  attention  of  the  civilised  world  was  immediately  drawn 
to  the  great  American  discovery.  Every  knoAvn  variety  of  ethers,  and  of  com- 
pounds containing  the  elements  of  ethers,  together  with  volatile  substances, 
gases,  and  vapours,  were  at  once  submitted  to  the  test  of  experiment.  It  is  pos- 
sible that  better  agents  than  those  now  in  use  Avill  hereafter  be  discovered,  but  for 
the  last  twenty  years  the  anaesthetic  practice  seems  to  have  settled  mainly  on  two 
agents — viz.,  sulphuric  ether,  with  which  the  discovery  Avas  made,  and  Avhich 
has  thus  far  shoAvn  itself  to  be  the  most  safe  and  manageable,  and  chloroform, 
which  is  more  portable  and  agreeable  in  its  odour,  but  Avhich  experience  has  shoAvn 
to  be  more  frequently  attended  Avith  danger  in  its  use.”  [Ed.] 


MODERN  HISTORY. 


13 


public  meeting  which  witnessed  the  presentation,  you  would  not  be 
astonished  at  anything  I did  allude  to,  or  did  not  allude  to;  or  that 
I failed  in  adverting  to  numerous  matters  to  which  I might  and 
ought  to  have  adverted. 

The  gravamen  of  your  charge  is  this  : — In  his  extempore  address 
to  me  on  the  occasion  in  question,  the  Lord  Provost  thought  fit  to 
allude  to  some  of  my  professional  investigations,  and  specially  to 
those  bearing  on  Anaesthetics,  Acupressure,  and  Hospitalism.  He 
spoke  of  the  application  of  chloroform  to  the  assuagement  of  human 
suffering  as  among  the  ‘ greatest  medical  discoveries  in  modern- 
times.’  In  replying  on  the  spur  of  the  moment  to  this,  among  other 
remarks  I stated  simply,  in  a sentence,  the  amount  to  which  chloro- 
form was  now  used  for  anaesthetic  purposes,  by  adverting  to  the 
great  extent  to  which  it  was  manufactured  by  one  single  firm  at  the 
l^resent  day.  I might,  if  there  had  been  time,  have  added  evidence 
of  the  extent  to  which  it  has  superseded  all  previous  anaesthetics,  by 
stating  the  amount  of  its  manufacture  by  other  firms  here  and  else- 
where. But  I had  many  other  subjects  to  advert  to  besides  chloro- 
form, and  only  a few  short  minutes  within  which  I was  expected  to 
include  them  all.  According,  however,  to  your  views,  I am  very 
deeply  blamable  for  not  taking  up  a subject  which  the  Lord 
Provost  did  not  allude  to — viz.  the  history  of  anaesthesia.  You 
hold  that  I should  have  entered,  to  a greater  or  less  extent,  into 
some  historical  notice  of  anaesthetic  agents.  The  history  of  them 
has  always  taken  me  a full  hour  in  my  University  lectures ; and  in 
these  lectures  I have  year  after  year  paid  heartily  every  due  compli- 
ment to  the  most  important  part  borne  in  the  consummation  of  the 
practical  application  of  anaesthetics  by  America,  particularly  by  the 
cities  of  Hartford  and  Boston,  and  specially  by  the  energy  and 
genius  of  Dr.  Morton.  Surely,  however,  it  would  have  been  sadly 
out  of  place,  on  such  an  occasion,  and  before  such  an  audience,  to 
have  shown  that,  before  I discovered  the  application  of  chloroform 
to  anaesflietic  purposes,  numerous  other  agents  had  been  previously 
suggested  and  used  for  the  same  object — as  sulphuric  ether  by  Drs. 
Jackson,  Morton,  and  Marcy  ; as  carbonic  acid  by  Dr.  Hickman,  in 
imitation  of  the  experiments  performed  for  ages  on  the  poor  dogs  at 
the  Grotto  del  Cane ; and  as  nitrous  oxide  (an  agent  extensively 
employed  as  a dentist’s  anaesthetic  at  the  present  hour),  and  first 
Xwoposed  for  ‘destroying  physical  pains ’ during  ‘surgical  operations’ 
by  Sir  Humphry  Davy.  Or  should  I,  in  your  opinion,  have  even 
gone  still  farther  back  in  therapeutic  history,  and  described  what. 


14 


HISTORY  OF  ANESTHESIA. 


doubtless,  as  a former  lecturer  on  Materia  Medica,  you  are  well 
acquainted  with — namely,  the  other  soporific  vapours  and  measures 
employed  by  different  olden  surgeons  in  Greek,  Eoman,  and 
mediaeval  times,  with  the  view  of  rendering  their  operations 
painless  to  the  patient  1 In  that  way  I could  have  easily  shown 
that  the  idea  of  making  a patient  anaesthetic  before  subjecting  his 
body  to  the  knife  or  cautery  was  a kind  of  knowledge  familiar  even 
to  non-professional  writers  of  mediaeval  and  of  later  times,  and  that 
some  theological  writers — like  Origen,  for  example,  in  the  third 
century^ — allude  to  the  artificial  production  of  anaesthesia  in  surgery 
as  a well-known  practice ; while  in  reference  to  Scotland  I might 
have  cited  Abbot  Bower,  who  lived  and  wrote  about  the  year  1400, 
within  ten  miles  of  Edinburgh,  as  telling  us  by  what  means  anaes- 
thesia in  surgery  was  accustomed  to  be  effected  in  those  days,  and 
what  they  gave  to  patients — ‘ secandi,  ut  possent  sine  dolore  secari;’ 
or  I might  have  adduced  the  monk  Jocelyn  as  alluding,  with  cir- 
cumstantial details,  to  an  alleged  instance  of  it  in  Scottish  hagiology, 
as  early  as  the  sixth  century.  All  this,  and  much  more,  might  have 
been  mentioned ; but  all  this  would  have  been  in  my  opinion — 
though  not  apparently  in  your  opinion — totally  misplaced  and 
grievously  out  of  order ; just  as  any  historical  disquisition  on  the 
previous  employment  of  the  ligature,  torsion,  etc.,  in  hemorrhage, 
would  have  been  when  I briefly  alluded  to  acupressure. 

In  the  way  of  a climax,  you  terminate  one  of  the  paragraphs  in 
your  letter  with  the  statement  that  I was  not  the  ‘first  man’  to 
inhale  a vapour  to  such  an  extent  as  to  destroy  sensibility.  Most 
certainly  I was  not ; and  certainly  I never  was  foolish  enough  to 
claim  to  be  so.  In  the  course  of  my  investigations  I have,  however, 
experimented  upon  myself  with  various  vapours,  the  innocuous  or  the 
poisonous  effects  of  which  upon  the  body  were  previously  altogether 
unknown  and  unascertained  ; and  I have  sometimes  suffered  in  con- 
sequence. As  a Professor  of  Therapeutics,  you  must  surely  be  well 
aware  that  the  first  experiment  of  breathing  a vapour  to*  such  an 
extent  as  to  destroy  sensibility  was  made  neither  in  America  nor 
in  our  own  days.  Without  adverting  to  the  acknowledged  fact  that 
it  was  accomplished  with  the  vapours  driven  off  from  hypnotic 

^ In  the  proceedings  of  one  of  the  councils  of  the  English  Churcli  held  at 
Exeter  in  the  year  1287,  the  statement  of  Origen  is  cited — “ llespondit  Origenes 
et  dicit — ‘ Quando  volunt  medici  incidere  aliquos,  vel  urere,  dant  cis  bibere 
aliquem  potum,  qui  facit  eos  profunde  dormire,  ita  quod  amentes  fiant,  et  sic 
non  sentiant.’  ” — (See  Wilkin’s  Concilia  Magnoe  Britannicc  et  Hihernicc,  vol.  ii. 

p.  162.) 


MODERN  HISTORY. 


15 


vegetable  extracts  by  the  older  surgeons,  from  Hugo  de  Lucca  and 
Theodoric  downwards,  let  me  remind  you  that  Sir  Humphry  Davy 
boldly — and  notwithstanding  he  had  witnessed  occasional  deaths  in 
animals  from  it — made  the  experiment  to  which  you  advert  many 
times  upon  himself  in  the  last  year  of  the  last  century  with  nitrous 
oxide,  and  further  found  that  headache  and  other  pains  disappeared 
under  its  influence. 

About  forty  years  ago,  Faraday  in  this  country,  and  Godman 
in  America,  showed,  as  the  result  of  their  observation  and  experience, 
that  the  effects  of  the  inhalation  of  the  vapour  of  sulphuric  ether 
were  quite  similar  on  the  nervous  system  to  those  produced  by  the 
inhalation  of  the  vapour  of  nitrous  oxide  gas — a truth  subsequently 
proved  by  many  pupils  in  many  chemical  and  other  schools  in  your 
country,  as  well  as  in  mine,*  by  their  inhalation  of  ether.  Your 
remarks,  as  far  as  I understand  them,  imply  that  it  is  your  belief 
that  Dr.  Morton  was  the  ‘ first  man’  of  ‘ sufficient  courage’  to  breathe 
‘a  vapour’  so  as  to  produce  a state  of  anaesthesia.  But  you  must 
know,  as  well  as  I do,  from  the  official  documents  laid  before  the 
Senate  of  the  United  States,  that  this  is  doubtful  even  as  regards 
the  course  of  matters  in  America ; for  it  appears  in  these  documents 
(1st),  that  Dr.  Jackson  avers  that  he  breathed  with  this  effect 
sulphuric  ether  earlier  than  Dr.  Morton ; (2dly),  that  before  Dr. 
Morton  made  the  ultimate  experiment  upon  himself  in  1846,  he 
made  it  first  upon  others,  and  particularly  upon  his  pupil  IMr.  Spears  ; 
and  (3dly),  that  two  years  previously  (or  in  1844),  Dr.  Marcy 
of  Hartford  in  Connecticut  had  successfully  excised  a tumour  from 
a man  who  had  been  rendered  anaesthetic  for  the  purpose  by  the 
vapour  of  sulphuric  ether ; whilst  at  that  same  early  date,  in  the 
same  city.  Dr.  Horace  Wells  had  extracted  teeth  from  a dozen  or 
more  patients  rendered  insensible  by  inhaling  nitrous  oxide  gas'* 
according  to  Davy’s  suggestion. 

^ I have  elsewhere  shown,  in  treating  of  the  therapeutic  history  of  sulphuric 
ether,  that  its  employment  by  inhalation — first  pointed  out  by  Dr.  Pearson  in  1796 — 
in  asthma,  etc.,  is  mentioned  by  many  writers  on  Materia  Medica  before  1846,  as 
by  Duncan,  Murray,  Brande,  Christison,  Thomson,  Pereira,  Nysten,  Barbier, 
Wendt,  Vogt,  Sundelin,  etc.,  in  Europe:  and  its  powers  of  producing  effects  like 
intoxication,  or  like  the  influence  of  nitrous  oxide  gas,  are  mentioned  in  America 
by  Godman  (1822),  Samuel  Jackson  (1833),  Wood  and  Bache  (1834),  etc. — (See 
Anccsthesia,  or  the  Employment  of  Chloroform  and  Ether,  p.  190.  Philadelphia, 
1849.) 

^ When,  however,  in  December  1844,  Dr.  Horace  Wells  conceived  the  idea 
that  the  inhalation  of  nitrous  oxide  gas  would  render  dentistry  anaesthetic,  he  was 
evidently  unaware  of  the  previous  suggestion  of  Sir  Humphry  Davy.  The  idea 


16 


HISTORY  OF  ANAESTHESIA. 


There  has  lately  been  raised  in  Boston  a monument  in  com- 
memoration of  it  being  the  birth-place  of  anaesthesia  in  dentistry 
and  surgery  in  1846.  But  have  the  erectors  of  this  monument  cut 
upon  it  the  names  of  either  of  your  fellow-citizens,  Dr.  Morton  or 
Dr.  Jackson,  as  the  first  investigators,  or  the  names  of  Warren  and 
Heyward,  as  the  first  Boston  hospital  surgeons  who  operated  upon 
patients  under  the  influence  of  sulphuric  ether]  Or  have  they 
generously  inscribed  upon  its  sides  any  allusions  to  the  fact  that  two 
years  previously  anaesthetics  had  been  inhaled  successfully  in  den- 
tistry and  surgery  in  the  city  of  Hartford  ] I have  been  informed 
that  there  does  not  yet  appear  upon  the  monument  the  name  of  a 
single  American  chemist,  dentist,  or  surgeon.  Is  it  so  ] You  have 
the  monument.  Have  you  not  had  the  man  or  men  ] 

You  commence  the  concluding  paragraph  of  your  letter  by 
averring  that  anaesthetic  inhalation  ‘ began’  (to  use  your  own  words) 
‘ in  this  country  [America],  and  was  first  used  in  the  extraction  of 
teeth,  and  afterwards  in  capital  operations  in  the  Mass.  General 
Hospital,  and  in  obstetrical  practice.’  Your  words  so  far  affirm  that 
anaesthetic  inhalations,  besides  being  first  employed  in  America  in 
dentistry  and  surgery,  were  in  your  country  also  first  used  in 
‘ obstetrical  practice.’  You  must  excuse  my  saying  that  this  last 
assertion  is  unaccountably  incorrect.  The  use  of  anaesthetic  inhala- 
tions in  obstetrical  practice  was  begun  and  extensively  followed  out 
in  Edinburgh,  weeks  or  even  months  before  it  was  tried  in  Boston 
or  in  America.  The  first  case  of  midwifery  in  which  sulphuric 
ether  was  adopted  as  an  anaesthetic  occurred  here  under  my  care  on 
January  19,  1847,  and  was  soon  afterwards  reported  in  the  journals 
of  the  day.  On  March  1,  1847,  was  published  by  me,  in  the  Edin- 
hurgh  Medical  Journal,  an  essay  on  the  subject,  containing  a series  of 
obstetrical  cases,  and  a longish  discussion  of  the  question  of  the 
applicability  of  anaesthetics  to  midwifery.  It  was  not,  however, 

occurred  in  consequence  of  a Mr.  Cooley,  at  a public  lecture  and  exhibition  of 
“laughing  gas”  at  Hartford,  striking  and  injuring  his  limb  against  the  benches 
without  suffering  pain.  On  the  subsequent  day,  to  test  the  truth  of  the  idea.  Dr. 
Wells  himself  breathed  deeply  and  fully  the  gas,  and  had  a molar  tooth  extracted 
from  his  own  mouth  by  Dr.  Riggs  without  pain.  This  was  the  first  ancesthetic 
operation  in  America.  Thus,  in  that  country,  the  idea  itself  of  producing  artificial 
anaesthesia  by  inhalation,  and  the  reduction  of  that  idea  to  actual  practice,  occurred 
at  Hartford  on  December  10  and  11,  1844.  The  first  anaesthetic  operation  at 
Boston — viz.  the  extraction  of  a tooth  from  a man  named  Frost — did  not  occur  till 
30th  September  1846,  or  nearJ^two  years  subsequently. — (See  Ofikial  Documents, 
Appendix,  pp.  91,  95,  etc.) 


MODEKN  HISTORY. 


17 


according  to  the  published  evidence  of  your  townsman,  Dr.  Channing, 
till  April  7,  that  the  first  case  of  the  employment  of  anajsthetics  in 
midwifery  occurred  in  America,  and  the  second  did  not  take  place 
till  May  5. — (See  Dr.  Channing’s  Treatise  on  Etherification  in  Ckild- 
hirtli,  p.  26.)  But  before  the  date  of  these  two  cases  the  practice 
had  been  fully  established  in  Edinburgh  and  elsewhere. 

Perhaps  you  and  I,  as  parties  implicated,  are  not  adequate  judges 
as  to  whether  your  statement  on  this  point  is  candid  and  creditable, 
or  utterly  the  reverse.  But  I willingly  leave  the  decision  of  this  to 
the  feelings  and  verdict  of  an  honourable  profession. 

You  think  me  greatly  blamable  because — in  the  way  of  omis- 
sion— I did  not  advert  to  the  previous  application  of  sulphuric  ether 
in  America  as  an  anaesthetic  when  the  employment  of  chloroform 
was  referred  to.  I think,  on  the  contrary,  that  you  are  infinitely 
more  blamable,  because,  without  the  slightest  reason  or  ground — 
and  in  the  way  not  of  omission  but  of  deliberate  commission — you 
have  in  this  letter  of  yours  attempted  to  appropriate  for  your  city  and 
country  what  indubitably  belongs  to  my  city  and  country — namely, 
the  credit  of  the  first  introduction  and  establishment  of  anaesthetic 
inhalation  in  obstetrical  practice. 

I have  the  honour  to  be,  yours  truly, 

J.  Y.  Simpson. 


Note. — The  official  documents  on  the  modern  history  of  ansesthesia  in  America, 
referred  to  in  the  preceding  letter,  are  contained  in  a thick,  but,  I believe,  un- 
published volume  of  seven  or  eight  hundred  pages,  printed  at  the  expense  of  Dr. 
Morton,  and  entitled  “Statements  supported  by  Evidence  of  Wm.  T.  G.  Morton 
on  his  Claim  to  the  Discovery  of  the  Anaesthetic  Properties  of  Ether,  submitted 
to  the  Honourable  the  Select  Committee  appointed  by  the  Senate  of  the  United 
States  Washington,  1853.  There  is  included  a “Report  to  the  House  of  Re- 
presentatives of  the  United  States  of  America,  vindicating  the  Rights  of  Charles 
T.  Jackson  to  the  Discovery  of  the  Anaesthetic  Effects  of  Ether  Vapours,  and 
disproving  the  Claims  of  W.  T.  G.  Morton  to  that  Discovery.”  Those  in- 
terested in  the  question  will  find  the  whole  volume  full  of  curious  and  important 
matter  in  the  way  of  memoirs,  documents,  affidavits,  examinations  of  witnesses, 
speeches,  etc. 


18 


liliSTOUY  OF  ANESTHESIA, 


CHAPTER  III. 

MODERN  HISTORY  OF  ANESTHESIA — Continued} 

Edinburgh,  April  1870. 

My  dear  Sir — A few  months  ago  I saw  in  an  American  general 
newspaper  the  gratuitous  attack  upon  me  which  you  had  published 
in  the  Boston  Medical  Journal,  but  of  which  you  had  forgotten  to 
send  me  either  an  intimation  or  a copy — doubtless  from  accident  and 
not  from  intentional  discourtesy.  Towards  the  beginning  of  the 
present  year,  I sent,  in  reply  to  your  groundless  accusation,  an 
answer  in  the  form  of  a letter  to  yourself ; and  subsequently  I 
received  from  you  a written  note  in  which  you  stated  you  were 
“ not  disposed  to  pursue  the  subject  farther.”  In  consequence,  I 
dismissed  the  matter  entirely  from  my  mind  ; and  I deeply  regret, 
both  for  your  own  sake  and  for  the  peace  and  character  of  our 
honourable  profession,  that  you  have  not  adhered  to  your  resolution. 
For  I have  just  received  a slip  of  printed  statement,  unaccompanied 
by  one  word  of  writing,  but  drawn  uj)  in  the  form  of  another  letter 
from  you  to  me,  in  which  jmu  continue  the  subject  in  terms  perhaps 
still  more  bitter  and  personal  than  before.  On  first  perusing  it,  my 

^ Second  Letter  to  Dr.  Jacob  Bigelow  of  Boston,  in  answer  to  the  following  : — 
Sir  James  Y.  Simpson.  Boston,  Feh.  27,  1870. 

Dear  Sir — In  the  Edinburgh  Daily  Review,  October  27,  1869,  is  contained 
some  account  of  an  ovation  given  in  Edinburgh  to  Sir  James  Y.  Simpson  in 
recognition  of  certain  material  advantages  enuring  to  that  place  from  his  residence 
in  the  city,  and  of  his  discovery,”  in  the  words  of  the  Lord  Provost,  ^Hhe 
greatest  of  all  discoveries  in  modern  times,  the  application  of  chloroform  to  the 
assuagement  of  human  suffering.” 

As  this  appeared  to  confound  what  may  w'ell  be  spoken  of  as  one  of  the 
greatest  discoveries  of  modern  times,  with  the  later  and  more  objectionable  use  of 
chloroform  to  imitate  its  result,  I endeavoured  to  define  the  respective  claims  of 
America  and  Scotland,  in  an  explanatory  article,  subsequently  published  in  the 
Boston  Medical  and  Surgical  Journal,  from  which  the  following  is  a brief 
extract : — 

“It  is  not  wonderful  that  in  the  designs  of  Providence  mediciual  agents 
should  exist,  capable  of  averting  pain  by  the  suspension  of  sensibility.  But  the 
wonder  is  that  after  mankind  has  borne  pain  ever  since  the  creation  of  their  race 
any  nerson  should  be  found  of  sufficient  courage  and  strength  of  conviction  to  put 


/ 


MODEllN  HISTORY.  19 

impression  was  that  it  was  too  querulous  in  tone  and  temper  to 
deserve  an  answer.  I then  thought  of  sending  back  a reply  to  you, 
stating,  simply  and  briefly,  that  the  new  imputations  in  it  were,  one 

tlirougli  the  untried  and  formidable  experiments  necessary  to  decide  whether  life 
could  continue  under  the  inhalation  of  a scarcely  respirable  vapour,  carried  to 
such  an  extent  as  to  destroy  sensibility  and  produce  apparent  death.  That  man 
was  not  Sir  James  Y.  Simpson.” 

My  remarks  were  replied  to  with  some  asperity  by  yourself,  in  a letter  sent  to 
me,  which  I supposed  to  be  of  a private  nature,  and  therefore  sent  you  the  follow- 
ing response,  not  then  knowing  that  its  publication  in  print  had  been  already 
ordered  by  yourself : 

Sir  James  Y.  Simpson,  Bart.  Boston,  U.  S.  A.,  Jan.  29,  1870. 

My  dear  Sir — I acknowledge  the  receipt  of  your  letter  of  the  3d  inst.,  and 
have  also  received  from  a friend  a copy  of  the  London  Medical  Times,  both 
expressing  disapprobation  of  remarks  published  by  me  in  the  Boston  Medical  and 
Surgical  Journal  for  November  25,  1869.  I at  first  had  a question  Avhether  T 
should  not  publish  a part  of  your  letter,  with  comments,  but  being  unwilling  to 
commit  an  act  of  discourtesy  towards  one  for  whom,  in  common  with  the  rest  of 
the  medical  world,  I entertain  an  exalted  respect,  I lost  sight  of  the  matter. 

I am  not  disposed  to  pursue  the  subject  farther,  now  that  it  seems  all  parties 
are  so  nearly  agreed  as  to  the  facts  of  the  discovery.  The  erroneous  impression 
seems  to  have  been  made  by  the  Lord  Provost  of  your  city,  whose  seemingly 
exclusive  assumption,  remaining  uncorrected  by  any  one,  shut  out  the  American 
hemisphere  from  the  credit  of  the  discovery. 

Poor  Morton  is  dead,  and  is  to  have  a monument.  He  was  not  a man  of  much 
cultivation  or  science.  But,  like  the  pioneers  who  have  penetrated  the  Arctic 
regions  and  the  deserts  of  Africa,  he  had  a hardihood  and  tenacity  of  purpose 
which  carried  him  where  more  cautious  and  perhaps  better  instructed  men  had 
failed  to  advance.  As  far  as  we  know,  he  is  the  only  man,  without  whom 
amesthetic  inhalation  might  have  remained  unknown  to  the  present  day. 

I have  requested  my  publishers  to  forward  to  you,  through  Messrs.  Sampson, 
Low,  & Co.,  a copy  of  my  work  called  Modern  Inquiries,  which  I shall  feel 
flattered  if  you  will  do  me  the  honour  to  accejjt. — Very  respectfully  yours, 

Jacob  Bigelow. 

But  as  your  letter  to  me  may,  by  its  publication,  tend  to  mislead  the  unpro- 
fessional part  of  the  community,  it  becomes  necessary  to  extend  my  reply,  "which 
I now  publish  as  final ; and  before  so  doing,  I have  read  your  letter  somewhat 
more  carefully  than  at  first  seemed  necessary. 

Let  me  say  at  the  outset,  that  you  misstate  my  words  when  you  represent  me 
as  saying  that  you  were  “ not  the  first  man  to  inhale  a vapour  to  such  an  extent 
as  to  destroy  sensibility.”  This  was  not  what  I said.  What  I did  say  of  this 
“untried  and  formidable  experiment ” is  reprinted  above.  Of  course  no  man 
could  experiment  decisively  on  himself.  No  man,  when  etherised,  could  operate 
in  any  way  on  himself,  nor  could  he,  adequately,  test  on  himself  the  degree  of 
insensibility  which  surgeons  require  in  their  operations. 

For  more  than  twenty  years  sulphuric  ether  has  been  extensively  used  in  the 
country  of  its  discovery.  It  has  proved  itself  to  be  one  of  the  safest  and  most 
manageable  of  medicinal  agents,  and  when  administered  to  others  may  be  fear- 
lessly urged  to  the  extent  of  profound  insensibility,  and  to  this  extent  it  is  always 


20 


HISTORY  OF  ANESTHESIA. 


and  all  of  them,  witliout  a shadow  of  foundation  in  fact,  and  even 
more  woithless  than  those  in  your  first.  But,  on  reperusing  it,  it 
struck  me  that  you  were  considering  yourself  a representative  and 

carried  by  liiimane  and  intelligent  surgeons.  It  is  only  chloroform  which  has 
piled  up  its  hundreds  of  cases  of  disaster  and  death. 

To  judge  from  the  array  of  rules  and  precautions  laid  down  in  the  British 
Medical  Journal  of  December  4,  18C9,  and  copied  as  a curiosity  in  the  Boston 
Medical  and  Surgical  Journal  of  February  17,  1870,  almost  a little  science  has 
grown  out  of  the  nominal  and  mostly  fruitless  precautions,  which  are  brought 
out  in  showy  opposition  to  possible,  and  too  often  probable,  deaths  from  the 
effects  of  chloroform. 

You  correctly  quote  the  words  of  the  Lord  Provost,  and  I am  quite  ready  to 
make  due  allowance  for  any  “nervousness  and  timidity”  which  prevented  you 
from  disclaiming  the  honour  of  being  one  of  the  greatest  medical  discoverers  of 
modern  times,  because  you  first  applied  chloroform  to  produce  anaesthesia.  But 
I felt  it  a duty,  in  behalf  of  my  own  country,  to  correct  the  statement  of  the 
Lord  Provost,  who  obviously  confounded  the  modern  discovery  of  a siLre  and  safe 
ancesthesia  which  belongs  to  Boston,  with  the  subsequent  application  of  chloro- 
form to  the  production  of  anaesthesia  in  Edinburgh  ; and  was  the  more  impelled 
to  do  this  because  the  same  mistake  not  unfrequently  occurs  through  the  ignorance 
or  inadvertence  of  English  writers ; and  especially  because  there  seemed  to  be  also 
a tendency,  in  some  of  your  own  Avritings,  to  foster  and  encourage  this  mistake. 

Here  was  the  gi'eat  medical  discovery  of  the  nineteenth  century,  perhaps  the 
greatest  since  the  creation  of  the  world  ; which  dated  from  experiments  made  in 
Boston,  in  Tremont  Street,  and  at  the  Hospital.  It  furnished  to  the  world  a 
comidete  and  oi^tional  exemption,  during  several  hours  at  a time,  from  the  severest 
pain ; an  amesthesia  sure  to  occur  when  desired,  in  every  case  without  fail,  and 
which  was  free  from  danger  (which  cannot  be  said  of  chloroform) ; an  amesthesia 
unlike  any  previous  one,  at  once  certain,  complete,  and  innocuous.  Such  was  this 
discovery  of  wonderful  perfection  at  its  very  outset.  No  European  surgeon  then 
pretended  to  have  heard  of  such  a discovery  before,  and  your  own  English  friends 
were  among  the  first  to  recognise  its  magnitude.  It  was  revealed  to  the  world, 
not  gradually,  but  flashed  upon  it  abruptly  : and  in  less  than  three  months  after- 
wards, “ in  grateful  and  unhesitating  recognition  of  it,  the  entire  civilised  world 
simultaneously  rose  up  to  hail  it  with  acclamatory  welcome.”  This  was  in  1846. 

AVe  may  now  turn  for  your  own  recognition  of  this  boon  to  the  human  race, 
to  the  Encyclopcedia  Britannica,  1854,  article  “ Ansesthesia,”  and  read  See 
Chloroform.  Under  the  latter  title,  we  find  an  elaborate  article  of  many  pages, 
containing  as  one  of  its  titles,  the  “ History  of  Ansesthetics,”  and  the  following 
paragraph  offered  as  this  History. 

“ The  vapour  of  chloroform  Avas  first  proposed  by  Dr.  Simpson  as  an  aiiEesthetic 
agent  in  surgery  and  midAvifery  in  1847.  For  a year  previous,  the  vapour  of 
sulphuric  ether  had  been  used  to  a considerable  extent,  both  in  America  and 
Europe,  for  the  purpose  of  inducing  insensibility  to  pain  in  surgical  operations,  it 
Avas  first  practically  adopted  for  this  purpose  in  1846,  by  Dr.  Morton,  a dentist  at 
Boston  in  America.  Subsequently,  Dr.  Charles  T.  Jackson,  of  that  city,  claimed 
the  right  of  having  suggested  to  Dr.  Morton  sulphuric  ether  as  an  agent  capable 
of  producing  insensibility  to  pain.  But  the  poAver  of  producing,  by  the  vapour  of 
sulphuric  ether,  an  insensibility  exactly  like  that  produced  by  the  inhalation  of 
nitrous  oxyde  gas,  had  been  long  previously  known,”  etc.  etc.  etc.,  and  so  on  back 


MODEHN  HISTORY. 


21 


cliampion  of  the  Boston  School  of  Medicine,  and  that  it  might  be 
well,  once  for  all,  to  answer  you  as  such  even  more  fully  and  per- 
fectly than  I had  done ; and  thus  state,  in  my  opinion,  the  great 

through  that  history  of  the  middle  ages  which  you  have  substantially  reproduced 
in  the  letter  you  have  sent  me. 

This,  from  an  article  signed  J.  Y.  S.,  is  offered  by  you  as  a “ History  of  Anaes- 
thetics ” — a history  of  the  great  modern  discovery  of  a sure  and  safe  anaesthesia  by 
ether,  completed  and  perfected  years  before  this  was  written.  Ko  “nervous  and 
timid”  condition  dictated  the  deliberate  sentences  in  this  “History  of  Anaesthetics” 
by  Dr.  J.  Y.  Simpson.  The  excuse  that  they  were  uttered  “ on  the  spur  of  the 
moment  ” Avill  hardly  serve  to  cover  this  inversion  of  historical  order  in  favour  of 
the  self- exaltation  of  the  writer.  This  was  not  a time  when  there  were  only  “ a 
few  short  minutes.”  The  ample  pages  of  the  Encyclopccdia  afforded  you  abundant 
opportunity  for  doing  liberal  justice  to  the  great  American  discovery,  had  you  so 
intended. 

Your  possible  reply  that  this  was  an  article  on  chloroform,  not  ether,  will 
hardly  avail  one  to  whom  the  whole  subject  of  anaesthesia  by  inhalation  was 
intrusted  in  a great  literary  and  standard  Avork,  and  who  availed  himself  of  this 
opportunity  chiefly  to  place  himself  conspicuously  in  the  foreground. 

The  letter  you  have  done  me  the  honour  to  address  to  me,  is  open  to  criticism 
of  the  same  general  character.  A considerable  part  of  it  is  occupied  with  a cloud 
of  antiquarian  dust,  of  which  the  only  apparent  result  is  to  obscure  the  truth,  and 
create  a confusion  in  the  mind  of  readers,  in  the  midst  of  which,  chloroform  may 
be  advantageously  introduced.  Your  logic  confounds  in  the  same  category  both 
beneficent  and  detrimental  agencies,  the  etherisation  practised  in  America,  and 
the  cruel  spectacle  of  the  asphyxiated  dogs  in  the  Grotto  del  Cane.  Xo  one  Avill 
disagree  with,  you  that  it  would  have  been  “ sadly  out  of  place  on  such  an  occasion 
and  with  such  an  audience,”  to  have  entered  into  the  details  of  “ soporific  vapours 
and  measures  employed  by  different  olden  surgeons  in  Greek,  Roman,  and  mediaeval 
times,  with  the  view  of  rendering  their  operations  painless  to  the  patient.”  In 
this  way  you  say  you  “might  easily  have  shown  that  the  idea  of  making  a 
patient  anaesthetic,”  was  a kind  of  knowledge  (what  knowledge  AAas  there?) 
familiar  even  to  non-professional  Avriters  of  mediaeval  and  of  later  times,  and  that 
“ some  theological  writers,  like  Origen  for  example,  in  the  third  century,  allude  to 
the  artificial  production  of  anaesthesia  in  surgery,  as  a Avell-knoAvn  practice.” 
You  also  quote  the  “ Abbot  Bower,”  and  the  “ Monk  Jocelyn,”  Avho  alludes  to  an 
instance  of  it  in  the  hagiology  of  Scotland,  etc. , and  so  on  doAA'n  to  the  times  and 
discoveries  of  Sir  Humphry  Davy,  about  seventy  years  ago. 

I did  not  desire  to  provoke  this  mediaeval  history  ; I only  Avished  that  you 
might  have  explained  AAdiat  the  Lord  Provost  evidently  did  not  understand,  the 
difference  betAveen  the  modern  discovery  of  anaesthesia  and  the  less  important  use 
of  chloroform. 

Everybody  kncAV  that  people  could  be  made  drunk  Avith  alcohol,  or  narcotised 
with  opium,  or  asphyxiated  and  poisoned  with  noxious  gases,  or  made  insensible 
Avith  nitrous  oxyde.  But  these  expedients  Avere  all  abandoned  even  by  their  strong 
partisans  as  uncertain  or  unsafe.  No  educated  surgeon  Avould  have  recommended 
one  of  them  in  a case  of  responsibility,  as  efficient  or  free  from  danger.  But  Avith 
* ether  came  “the  triple  and  demonstrated  discovery,  not  of  a probable  and  untrust- 
worthy, but  of  an  inevitable,  complete,  and  safe  ansesthesia.” 

Your  prolix  mediaeval  history  is  simj)ly  irrelevant,  and  its  application  illogical. 


22 


HISTORY  OF  AMSTHESIA. 


things  which  the  Boston  School  had  done — and  had  not  done — in 
the  cause  of  anaesthetics;  and  how  mistakes  and  errors  might  possibly 
have  originated  on  the  subject,  between  your  city  and  other  places, 
which  I trusted  could  be  fully  removed.  Hence  pardon  me  address- 
ing to  you  the  following  observations. 


A man  who  would  believe  your  deductions  from  it,  would  also  believe  that  baloons 
and  gas-lights  were  known  to  the  ancients  because  the  classical  writers  believed  in 
wax  wings  and  subterranean  fires.  Sir  Humphry  Davy  must  be  exonerated  from 
all  practical  knowledge  of  ansesthetic  inhalation.  Otherwise  he  is  chargeable  with 
all  the  tortures  of  amputation  and  lithotomy  which  have  taken  place  since  he 
made  the  discovery  and  concealed  it. 

The  great  discovery  having  been  made  of  a secure,  perfect,  and  always  attain- 
able anaesthesia,  the  substitution  for  ether  of  chloroform,  preferable  in  odour  and 
bulk,  but  so  far  more  dangerous  that  no  life  insurance  company  would  take  the 
risks  as  equal,  is  a matter  of  much  less  important  detail. 

And  so  of  the  further  application  of  the  newly  discovered  anaesthesia  to  the 
different  forms  of  pain.  You  object  to  my  statement  which  you  quote,  that 
anaesthetic  inhalalation  “ began  in  America,  and  was  first  used  in  the  extraction 
of  teeth,  and  afterwards  in  capital  operations  in  the  Mass.  General  Hospital,  and 
in  obstetrical  practice  ; ” the  last  three  words  of  which,  afford  you  the  text  for 
several  paragraphs  of  animated  invective  with  which  you  close  your  letter.  Had  I 
attached  the  same  importance  which  you  do  to  your  agency  in  this  detail  of  ob- 
stetric application,  I should  probably  have  given  it  more  prominence  and  careful 
attention.  I do  not  now  question  that  you  were  the  first  to  use  ether  in  labour, 
but  who  first  introduced  ansesthetics  in  obstetrical  practice  is  a matter  of  limited 
importance.  Soon  after  the  great  discovery  of  etherisation  tvas  nnade,  the  pages 
of  medical  journals,  and  the  meetings  of  medical  societies,  were  crowded  with  re- 
ports of  its  application  to  most  of  the  ills  and  difficulties  which  flesh  is  heir  to — 
colic  and  convulsions,  dislocations,  hernia  and  parturition,  neuralgia,  gout,  gravel, 
and  gall-stones — each  heralded  by  its  respective  claimant  as  an  original  discovery. 
The  several  glories  of  these  ex-jjost-facto  benefactors  of  man,  may  perhaps  pass  into 
oblivion,  unless  rescued  by  some  future  Council  of  Edinburgh.  The  world  is  more 
interested  about  the  origin  of  great  discoveries  than  the  question  who  afterwards 
suggested  their  various  applications. 

Finally  you  allude  to  the  monument  erected  in  Boston  by  a public-spirited 
individual,  and  which,  among  others,  bears  the  following  inscription  : — “To  com- 
memorate the  discovery  that  the  inhaling  of  ether  causes  insensibility  to  pain  ; 
first  proved  to  the  world  at  the  Massachusetts  General  Hospital,  in  Boston, 
October,  A.D.  1846.”  You  inquire  why  no  individual  names  were  inscribed  upon 
it.  I reply,  because  it  was  intended  only  to  commemorate  the  city  of  Boston  as 
the  birth-place  of  the  discovery  ; perhaps  in  prophetic  view  of  some  effort  to  con- 
fuse the  history  and  relations  of  the  whole  subject,  and  then  to  connect  some  other 
name  and  place  with  this  discovery. 

Mankind  are  not  apt  to  forget  their  benefactors,  nor  even  those  who  stand  in 
the  place  of  benefactors.  They  cheerfully  unite  in  ovations  and  festivities  given 
to  distinguished  men  by  “their  friends  and  fellow-citizens.”  But  the  suffering 
and  now  exempted  world,  will  not  forget  the  poor  dentist,  who,  amid  poverty, 
privation,  and  discouragement,  matured,  revealed,  and  established  the  most  bene- 
ficent discovery  which  has  blessed  humanity  since  the  primeval  days  of  paradise, 
— Your  obedient  servant,  Jacob  Bigelow.  [Ed.] 


MODERN  HISTORY. 


23 


r.  TENDENCY  TO  CONFUSION  FROM  THE  DISCOVERY  OF  CHLOROFORM 
RAPIDLY  FOLLOWING  THAT  OF  SULPHURIC  ETHER. 

From  some  communications  which  I have  lately  received  from 
America,  I find  that  your  observations  have  stirred  up  there,  in 
some  minds,  the  idea  that  I have  held  up  the  introduction  of 
chloroform  as  an  ansesthetic  in  Edinburgh  to  be  antecedent,  in 
point  of  time,  to  the  introduction  of  sulphuric  ether  in  Boston.  I 
feel  sure  that  you  and  I will  mutually  agree  that  never  anything  so 
wild  or  extravagant  was  hinted  or  suggested  by  either  of  us.  The 
first  case  of  an  anaesthetic  operation  under  sulphuric  ether  occurred 
at  Boston  on  the  30th  September  184G.  The  first  case  of  an 
anaesthetic  operation  under  chloroform  occurred  at  Edinburgh  on 
the  15th  November  1847.  During  the  intervening  thirteen  months, 
I had  worked  much  with  sulphuric  ether  in  midwifery,  etc. ; and 
some  of  our  surgeons,  here  and  elsewhere,  had  used  it  more  or  less 
extensively ; but  it  was  not  by  any  means  adopted  by  all. 

At  the  same  time,  you  m.ust  allow  me  to  remark  that  the  ideas 
on  the  subject  in  your  own  mind,  which  have  excited  you  to  write, 
have,  it  appears  to  me,  become  chiefly  bewildered  and  confused  in 
consequence  of  one  thing — namely,  of  the  rapidity  with  which 
chloroform  thus  followed  as  an  anaesthetic  after  the  discovery  of 
sulphuric  ether ; and  in  consequence  also  of  the  relative  practical 
adaptability  and  superiority  of  the  former  in  many  respects,  leading 
speedily  to  its  general  substitution  in  Europe,  Asia,  Australia,  etc., 
for  the  latter. 

In  the  Dispensatory  of  the  United  States  of  America,  Drs.  Wood 
and  Bache,  when  speaking  of  the  use  of  sulphuric  ether  for  inhalation 
in  medicine,  observe — “ Many  years  ago  [1796,  etc.]  its  use  in  this  way 
was  proposed  by  Drs.  Beddoes,  Pearson,  and  Thornton,  in  England, 
as  a remedy  in  certain  diseases  of  the  lungs.  As  early  as  1805,  Dr. 
Warren  of  Boston  employed  ethereal  inhalation  to  relieve  the  distress 
attending  the  last  stage  of  pulmonary  inflammation.  About  the  year 
1812,  in  Philadelphia,  at  a time  when  nitrous  oxide  was  the  subject 
of  popular  lectures,  the  vapour  of  ether  was  frequently  breathed  from 
a bladder  for  experiment  or  diversion,  and  its  effects  in  producing  a 
transient  intoxication  analogous  to  that  caused  by  the  nitrous  oxide 
were  observed.”  Now,  if  in  Boston  in  1805,  or  in  Philadelphia  in 
1812,  the  inhalation  of  sulphuric  ether  had  been  tried  to  a sufficient 
depth  for  its  anaesthetic  effects  to  be  discovered  in  dentistry  and 


24 


HISTOEY  OF  ANESTHESIA. 


surgery, — while  the  superior  anaesthetic  powers  and  higher  practical 
properties  of  chloroform  in  midwifery,  as  well  as  in  surgery,  re^ 
mained  undetected  till  1848, — then  all  this  storm  of  mist  and 
obscurity,  which  has  been  attempted  within  the  last  few  months  to 
be  stirred  up  on  the  matter,  would  have  been  an  entire  failure,  or 
indeed  an  entire  impossibility.  For  while  the  glory  of  first  dis- 
covering the  induction  of  surgical  anaesthesia  by  the  vapour  of  sul- 
phuric ether  would  have  been,  as  it  undoubtedly  is,  American  in  its 
birthplace  and  origin,  a Lord  Provost  of  Edinburgh  in  1869 — or 
forty  or  fifty  years  afterwards — knowing  and  looking  to  the  fact 
that  chloroform  in  Scotland  and  in  other  parts  of  Europe,  etc.,  had 
for  the  previous  twenty  years,  if  not  entirely,  yet  nearly  entirely, 
superseded  the  use  of  sulphuric  ether,  and  by  its  general  adoption 
diffused  greatly  and  everywhere  the  practice  of  anaesthesia — might 
surely,  without  vindictive  challenges  and  recrimination  on  your  part, 
have  ventured  to  speak  of  “ the  discovery  and  application  of  chloro- 
form to  the  assuagement  of  human  suffering”  as  “ the  greatest  of  all 
discoveries  in  modern  times  in  connection  with  medicine.”  ^ 

An  illustration,  however,  may  show  my  meaning  better  than  an 
abstract  statement.  We  have  now  at  present  in  practice  various 
means  of  abolishing  the  pain  attendant  upon  surgical  ojoerations,  as 
nitrous  oxide  gas,  sulphuric  ether,  chloroform,  etc. ; and  the  olden 
surgeons  had  others.  We  have  various  means  also  of  arresting  the 
hemorrhage  attendant  upon  these  operations,  as  cauterisation,  torsion, 
deligation,  acupressure,  etc.  These  hemostatic  means  all  arrest 
hemorrhage  by  closing  up,  in  one  way  or  other,  the  open  mouths  of 
the  cut  vessels.  They  get  at  one  and  the  same  end  by  three  or  four 
different  means ; but  because  these  means  have  been  suggested  at 
three  or  four  different  and  distant  times,  any  one  displacing  the 
former  does  not  of  necessity  require  to  be  apologised  for  and  de- 
nounced, as  you  seem  rather  to  think  ought  to  be  the  fact  in  the 
case  of  anaesthetics.  Or,  take  another  illustration : — The  greatest 
thought  ever  perhaps  broached  in  practical  medicine,  was  the  sug- 
gestion in  relation  to  small-pox — and  to  probably  other  fatal  diseases, 
destined  to  occur  only  once  in  life — that  their  severity  and  fatality 
might  be  averted,  if  instead  of  the  contagious  poison  producing  them 
being  allowed  to  enter  in  limitless  quantities  into  the  body  by  respira- 
tion, it  could  be  inserted  in  very  small  and  definite  quantities  by 
inoculation  through  the  skin.  Hence  small-pox  inoculation,  and  the 

1 See  the  report  of  the  Lord  Provost’s  speech,  as  given  in  the  Scotsman  of  27ti 
October  1869. 


MODEKN  HISTORY. 


25 


wonderful  protection  obtained  by  it  against  the  fatality  of  small- 
pox ; — an  idea  brought  from  Asia  and  Turkey,  and  acted  on  in 
England  in  the  beginning  of  the  last  century.  Ere,  however,  the 
century  was  closed,  a new  variety  of  matter  was  proposed  to  be 
inoculated  by  Dr.  Jenner,  and  proved  infinitely  a greater  success. 
The  material  used  by  the  old  Asiatic  and  Turkish  inoculators  was 
small-pox  matter  taken  directly  from  pustules  on  the  bodies  of 
human  beings  who  were  infected  with  small-pox.  The  material 
used  by  Jenner  was  small-pox  matter  taken  from  the  pustules  pro- 
duced on  the  udders  and  nipples  of  cows  who  were  infected  with 
small-pox  poison.  That  vaccination  was  thus  a modification  of  ' 
small-pox  inoculation,  has  never,  however,  been  allowed  to  detract 
one  iota,  I believe,  from  the  merit  of  the  great  pathological  and 
practical  revolution  produced  by  Dr.  Jennet.  And  the  two  dis- 
coveries— or  two  prophylactics  against  small-pox — the  Asiatic  and 
English  variolous  and  vaccine  inoculation — have  never  clashed  and 
been  entangled  together  : for  they  were  in  our  own  country  upwards 
of  half-a-century  or  more  separate  from  each  other  in  the  date  of 
their  introduction  and  discovery.  Neither,  I think,  would  the 
relative  merits  of  the  two  anaesthetics,  the  American  and  the  English, 
sulphuric  ether  and  chloroform,  have  been  commixed  in  the  manner 
in  which  they  have  been  confused  by  you  and  others,  had  their  dis- 
coveries been  separated  by  upwards  of  half-a-century  also. 


II.  EARLIEST  ANESTHETIC  OPERATIONS  IN  AMERICA,  AND  THEIR 
CONNECTION  WITH  HARTFORD  AND  BOSTON. 

From  ancient  times  anaesthesia  in  surgery  has  been  attempted 
by  various  agents  or  anaesthetics  ; but  till  latterly  with  very  uncer- 
tain or  equivocal  effects.  At  the  present  time  three  kinds  of 
anaesthetics  are  principally  and  specially  used  in  practice,  viz. — 

1.  Nitrous  oxide  gas,  now,  I believe,  employed  extensively  in 
dental  surgery,  etc.,^  since  it  was  reintroduced  a few  years 
ago  by  Dr.  Evans  of  Paris  ; but  originally  suggested  by 
Sir  Humphry  Davy  in  1800,  and  practically  and  success- 
fully employed  by  Dr.  Horace  Wells  in  Hartford,  in  1844. 

2.  Sidphuric  ether,  first  used  by  Dr.  Morton,  at  Boston,  in  1846. 

3.  Chloroform,  first  employed  in  Edinburgh  in  1847. 

^ See,  for  example,  papers  in  the  Lancet  for  2cl  and  9th  April  1870,  by  Mr. 
Fox,  “On  the  use  of  Nitrous  Oxide  Gas  as  an  Anfesthetic  in  Surgery.” 


26 


HISTORY  OF  ANAESTHESIA. 


There  have  been  latterly  used,  also,  from  time  to  time,  various 
minor  anaesthetic  agents,  but  none  of  them,  I believe,  to  any  great 
practical  extent ; though  in  all  likelihood  some  will  yet  be  dis- 
covered of  types  superior  to  any  we  as  yet  know.  In  my  former 
letter  to  you,  and  on  different  other  occasions,  I have,  with  other 
writers,  shown  that  the  ancient  surgeons — Mediaeval,  Eoman,  and 
Greek — were  long  employed  in  the  search  after  surgical  anaesthetics, 
and  so  far  succeeded,  by  making  their  patients  inhale  the  fumes  of 
narcotic  vegetable  extracts,  drink  solutions  of  them,  etc.  etc.  Ap- 
parently afraid  that  the  history  and*  uses  of  these  olden  surgical 
anaesthetics  would  detract  from  the  merit  of  the  Medical  School  of 
Boston  in  the  discovery  of  the  anaesthetic  properties  of  sulphuric 
ether,  you  bitterly  denounce  in  your  letter  to  me  the  study  and 
consideration  of  them.  Best  assured  that  no  wishes  or  declamations, 
either  on  your  part  or  mine,  will  wash  out  or  obliterate  that  or  any 
other  points  of  the  past  history  of  surgery.  “ I did  not  desire,”  you 
exclaim,  “ to  provoke  this  mediaeval  history.”  But  was  not  your 
sole  cause  of  complaint  against  me  this — that  in  speaking  to  the 
Town-Council  of  Edinburgh  one  or  two  sentences  regarding  chloro- 
form, I omitted — most  erroneously  in  your  opinion — to  refer  to,  or 
speak  of,  the  past  history  of  anaesthetics,  say  for  a quarter  or  half  a 
century  backward!  “Your  prolix  mediaeval  history,”  you  again 
querulously  complain,  “is  simply  irrelevant,  and  its  application 
illogical.”  It  is  in  no  degree  illogical ; but  I believe  that  it  would 
have  been  quite  irrelevant  if  brought  before  the  Town-Council  of 
my  native  city.  My  letter  to  you,  as  you  further  again  bitterly 
observe,  is  “ occupied  with  a cloud  of  antiquarian  dust,  of  which  the 
only  apparent  result  is  to  obscure  the  truth  and  create  a confusion 
in  the  mind  of  the  readers,  in  the  midst  of  which  chloroform  may  be 
advantageously  introduced.”  Surely,  my  dear  sir,  this  undignified 
and  calumnious  sentence  is  unworthy  alike  of  the  heart  and  of  the 
pen  of  Dr.  Jacob  Bigelow,  and  requires  no  answer  from  me. 

But,  dismissing  the  history  of  the  olden  forms  of  anaesthetics,  let 
me  direct  your  attention  for  a moment  to  an  episode  in  their  more 
modern  history  connected  with  Boston  and  its  Medical  School.  You 
properly  claim  for  yourselves  true  and  vast  merit  from  the  discovery 
and  application  of  sulphuric  ether  in  dentistry  and  surgery.  Indeed, 
you  almost  seem  to  me  to  insinuate  in  your  letter  that  the  medical 
world  should  have  been  ever  afterwards  contented  to  use  sulphuric 
ether,  and  it  alone.  For  you  now  argue  and  hold  that  sulphuric 
ether  (see  your  last  letter)  formed  a “ discovery  of  ivonderful  perfection 


MODERN  HISTORY. 


27 


at  its  very  outset.**  I think,  however,  Dr.  Channing  (pp.  322  and 
337)  alludes  to  you  yourself  using  chloroform  in  some  midwifery 
cases ; and  early  in  the  practice  of  etherisation  in  midwifery,  I 
found  that  no  busy  obstetric  practitioner  could  extensively  employ 
sulphuric  ether  without  inevitably  carrying  about  with  him,  and 
upon  his  clothes,  an  odour  so  disagreeable  to  many  other  patients 
and  other  houses,  as  to  make  his  presence  there  aught  but  desirable. 
Other  Boston  surgeons  have  tried,  at  least,  other  anaesthetics  besides 
sulphuric  ether,  as  if  they  did  not  look  upon  it  in  the  way  of  “ won- 
derful perfection”  as  you  do.  I have  read  also  of  your  accomplished 
son,  Dr.  Henry  Bigelow,  excising  the  mamma  after  he  had  placed 
the  patient  under  the  anaesthetic  influenccj  not  of  sulphuric  ether  but 
of  nitrous  oxide  gas.^ 

In  your  two  late  articles  you  have  carefully  eschewed  all  refer- 
ence to  this  last  special  anaesthetic,  nitrous  oxide  gas,  in  despite  of 
its  being  now  largely  and  successfully  employed  in  Paris,  London, 
and  elsewhere  in  tooth-extraction.  I wish,  on  the  contrary,  to  recall 
your  attention  particularly  to  it.  For  let  me  here  again  put  you  in 
mind  that  the  first  anaesthetic  operation  under  sulphuric  ether  at 
Boston  occurred  on  the  20th  September  1846,  when  Dr.  Morton 
drew  a tooth  from  the  head  of  Eben  Frost,  who  had  been  previously 
placed  under  the  influence  of  the  anaesthetic  vapour.  Nearly  two 
years  previously,  however,  or  on  the  11th  December  1844,  the  same 
anaesthetic  operation  was  as  successfully  performed  at  Hartford,  the 
anaesthetic  inhaled  being  not  sulphuric  ether  but  nitrous  oxide  gas, 
and  the  patient  being  Dr.  Wells  himself,^  to  whose  mind  the  idea 
had  suggested  itself  on  the  night  previously,  that  a person  under  a 
deep  dose  of  nitrous  oxide  might  not  feel,  when  in  that  state,  the 

1 Official  Documents,  p.  323. 

* The  account  which  Dr.  Riggs  has  given,  in  his  official  examination  in  1852, 
of  this  first  anaesthetic  operation  in  America  is  sufficiently  graphic.  Messrs. 
Cooley,  Wells,  Collin,  etc.,  were  present.  Dr.  Riggs  says:  “A  few  minutes 
after  I went  in,  and  after  conversation.  Dr.  Wells  took  a seat  in  the  operating 
chair  ; I examined  the  tooth  to  he  extracted  with  a glass,  as  I usually  do  ; Wells 
took  a bag  of  gas  from  Idr.  Colton,  and  sat  with  it  in  his  lap,  and  I stood  by  his 
side ; Wells  then  breathed  the  gas  until  he  was  much  affected  by  it ; his  head 
chopped  back,  I put  my  hand  to  his  chin  ; he  opened  his  mouth  and  I extracted 
the  tooth  ; his  mouth  still  remained  open  some  time  ; I held  up  the  tooth  in  the 
instrument  that  the  others  might  see  it ; they  standing,  partially  behind  the  screen, 
were  looking  on.  Dr.  Wells  soon  recovered  from  the  inffuence  of  the  gas,  so  as  to 
know  what  he  w’as  about,  discharged  the  blood  from  his  mouth,  swung  his  hand, 
and  said,  ‘A  NEW  era  in  tooth-pulling.’  He  said  it  did  not  hurt  him  at  all. 
We  were  all  much  elated,  and  conversed  about  it  for  an  hour  after.” — (See 
Appendix,  Dr.  Colton’s  Statements,  p.  95.) 


28 


HISTORY  OF  ANiFSTHESIA. 


pain  of  tooth-drawing  and  other  operations,  because  he  had  seen  Mr. 
now  Colonel,  Cooley  w^ound  his  limbs  severely  against  the  benches 
without  feeling  any  suffering  from  these  injuries.^ 

A short  and  adequate  experience  of  a dozen  or  more  cases  soon 
satisfied  Dr.  Horace  Wells  and  others  that  teeth  could  in  this  way 
be  extracted  without  pain,’*  however  much  trouble  there  might  be 
in  preparing  and  applying  the  gas  with  the  imperfect  means  then  in 
existence.  His  affidavits  of  its  success  (see  footnote)  are  unchal- 
lengeable. His  friend  Dr.  Riggs  drew  six  teeth  from  one  patient,  at 
one  sitting,  without  any  suffering  whatever.  During  this  time  also 
he  seems  to  have  discovered  the  great  point  which  we  now  knoAv  to 
be  so  essential  in  the  successful  exhibition  of  nitrous  oxide — namely, 
that  it  should  be  breathed  as  pure  as  possible,  and  without  any 
mixture  of  atmospheric  air.* 

Elated  with  his  discovery,  he  in  a week  or  two  proceeded  to 
Boston,  in  order  to  lay  it  before  the  medical  faculty  there,  and  show 
its  effects.  He  first  made  it  known  there — according  to  his  own 
account — to  Drs.  Warren,  Heyward,  Jackson,  and  Morton,  the  last 

^ This  occurrence  took  place  at  a public  exhibition  of,  and  lecture  on,  laughing 
gas,  at  Hartford,  by  Mr.  Colton.  The  advertisement  for  Mr.  Colton’s  lecture, 
published  in  the  Daily  Times  of  December  10,  1844,  has  been  republished  in  the 
Daily  Joimial  for  February  of  the  present  year.  “ The  entertainment,”  says  the 
advertisement,  “is  seientific  to  those  who  make  it  scientific.”  For  a full  account 
of  the  effects  produced  by  the  gas  upon  some  of  the  most  distinguished  men  in 
Europe,  Mr.  Colton  refers  to  Hooper’s  Medical  Dictionary,  where  an  abstract  of 
the  experiments  of  Sir  Humphry  Davy  is  given. 

2 In  his  pamphlet,  and  elsewhere.  Dr.  Wells  brings  forward  sworn  affidavits, 
from  different  patients,  of  the  anaesthetic  effects  of  the  nitrous  oxide  gas.  Thus, 
for  example,  Mr.  Burleigh  states  that,  after  having  had  an  opportunity  of  witnes- 
sing its  effects  on  several  persons,  he  himself  breathed  it,  and  he  adds,  “two 
carious  teeth  were  extracted  from  my  low'er  jaw  without  the  least  suffering  on  my 
part,  though,  ordinarily,  owing  to  the  firmness  with  which  my  teeth  are  fixed  in 
my  jaw,  I suffer  extreme  pain  from  their  extraction.”  “Dr.  Wells,”  states  Mr. 
Goodrich,  “was  most  successful  in  extracting  for  me  a large,  firmly-set,  bicuspid 
tooth,  without  the  slightest  sensation  of  pain.  I also  witnessed,  soon  after,  a 
repetition  of  the  same  process  by  Dr.  Wells  upon  several  individuals,  accompanied 
in  every  instance  with  perfect  success,”  etc. 

^ See  Dr.  Morton’s  volume  of  Official  Documents,  p,  29,  etc.  “The  less  at- 
mospheric air  is  admitted  into  the  lungs,  with  any  gas  or  vapour,  the  better — the 
more  satisfactory  will  be  the  result  of  the  operation.”  Dr.  IMorton,  unaw'are  of 
the  rules  for  breathing  nitrous  oxide,  denounces  this  observation  of  Dr.  Wells  as 
“ inconsistent  with  fact.”  “This  agent” — nitrous  oxide  gas — “wewr,”  stoutly 
avers  Dr.  Morton,  “was,  nor  can  it  ever  be,  of  any  value  ” (Official  volume,  p.  12). 
Dr.  Morton’s  first  chapter  in  this  volume  against  nitrous  oxide  reads  now,  I fear, 
as  only  an  exhibition  of  jealousy  and  ignorance  ; and  Professor  Jackson’s  letter 
against  Dr.  Wells  (see  p.  472  of  the  same  volume)  is  still  more  painful  and  inex- 
cusable in  its  tone  and  character. 


MODERN  HISTORY. 


29 


gentleman  being  a former  pupil  and  partner  of  his  own,  and  destined 
to  be  the  future  discoverer  of  anaesthesia  by  sulphuric  ether.^ 

A case  of  amputation  was  about  to  be  performed  by  Dr.  Hey- 
ward in  the  Massachusetts  Hospital,  but  was  put  off  for  some  days. 
After  Dr.  Wells  had  addressed  Dr.  AYarren’s  class  on  the  subject,  it 
was  proposed  that  the  anaesthetic  should  be  tried  in  a case  of  tooth- 
extraction.  “ Accordingly,”  writes  Dr.  Wells,  “ a large  number  of 
students,  with  several  physicians,  met  to  see  the  operation  performed 
— one  of  their  number  to  be  a patient.  Unfortunately,”  he  con- 
tinues, “ for  the  experiment,  the  bag  was  withdrawn  much  too  soon, 
and  he  was  but  partially  under  its  influence  when  the  tooth  was 
extracted.  He  testified  that  he  experienced  some  pain,  but  not  as 
much  as  usually  attends  the  operation.”  The  audience  pronounced 
it  a humbug  affair  and  an  imposition,  and  Dr.  Wells  was  hissed  away, 
left  Boston,  and  gave  up,  for  a time,  his  profession  Avith  disgust  and 
vexation.  “ He  was  laughed  at,”  contemptuously  writes  Dr.  Charles 
T.  Jackson,  ‘‘for  his  pretensions,  and  left  Boston.  No  one  ever  be- 
lieved in  his  story.”  ^ According  to  the  statement  of  Dr.  Morton, 
his  friend  and  former  partner  (who  accompanied  him),  “ the  spec- 
tators laughed  and  hissed  ; the  meeting  broke  up,  and  w^e  were 
looked  upon  as  having  made  ourselves  very  ridiculous.”*  In  these 
experiments,  Dr.  Wells,  as  I have  said,  used  the  nitrous  oxide  gas 
which  in  1800  Sir  Humphry  Davy  had  in  England  found  capable 
in  his  own  person  of  removing  intense  physical  pain,  and  which  he 
consequently  suggested  as  “ capable  of  destro^dng  physical  pain 
during  surgical  operations  in  which  no  great  effusion  of  blood  takes 
place.”  In  your  late  letter  to  me,  however,  you  maintain  that  “ Sir 
Humphry  Davy,”  to  quote  your  own  extraordinary  words,  “ must 
be  exonerated  from  all  practical  knowledge  of  anaesthetic  inhalation, 
otherwise  he  is  chargeable  with  all  the  tortures  of  amputation  and 
lithotomy  which  have  taken  place  since  he  made  the  discovery  and 
concealed  it.”  You  have  used,  I knoAv,  the  same  wild  and  irrelevant 
argument  against  Dr.  Jackson  which  you  here  use  against  Sir 
Humphry  Davy,  forgetting  that  their  profession  Avas  that  of  chemists 
and  not  of  surgeons.  Have  you  really  any  hope  or  expectation  that, 
either  in  Boston  or  elseAvhere,  such  a violent  observation  as  I have 
just  noAv  quoted,  Avill  blot  out  and  erase  in  some  cabalistic  way 

^ See  the  Appendix  to  Dr.  Morton’s  volume  of  Official  Documents,  pp.  11,  14, 
15,  etc.  ; and  Dr.  Wells’s  pamphlet  about  the  history  of  the  discovery  of  the 
application  of  nitrous  oxide  gas,  p.  6,  etc. 

^ Official  Documents,  p.  472. 


Ibid.  p.  47. 


30 


HISTORY  OF  ANAESTHESIA. 


the  remarkable  fact  that  Sir  Humphry  Davy,  seventy  years  ago, 
relieved  intense  physical  pain  in  his  own  person  by  breathing  nitrous 
oxide  gas,  or  that  he  suggested  that  it  might  be  used  as  an  anaesthetic 
in  some  surgical  operations,  and — published  the  suggestion  1 

But  now  mark  what  subsequently  occurs.  An  American  dentist 
works  out  to  its  practical  results  the  suggestion  published  in  Eng- 
land half-a-century  before  by  Sir  Humphry  Davy,  and  which  you 
seem  to  wish  to  efface  from  anaesthetic  records,  and  he  travels  a long 
distance  to  place  the  important  result  before  the  Medical  School  at 
Boston,  and  some  surgeons  of  the  Massachusetts  Hospital.  There 
is  a slip  in  the  single  experiment  allowed  him.  He  is  spurned  and 
hooted  away.  In  doing  this  the  Medical  School  of  Boston  thus  de- 
lays the  wdiole  subject  of  artificial  surgical  anaesthesia  for  a couple 
of  years.  \Yas  not  the  Medical  School  of  Boston  then,  in  your 
violent  language,  “ chargeable  with  the  continuance  of  operative 
tortures  ” for  that  period,  much  more  than  Sir  Humphry  Davy  1 
Did  not  your  school  stamp  out — and  thus  prevent  for  two  years  more 
— the  “ most  beneficent  discovery,”  to  use  again  your  own  grandi- 
loquent words,  “ which  has  blessed  humanity  since  the  primeval  days 
of  paradise?”  ^ I am  using  here  not  my  language  and  logic,  but  yours. 

It  is  perhaps  here  unnecessary  to  add  that  there  is  sufficient 
evidence  that  Drs.  Wells,  Marcy,  and  Goodrich  debated  the  question 
together  whether  sulphuric  ether  would  not  be  an  agent  preferable 
to  nitrous  oxide  in  these  experiments,^  but  Dr.  Marcy  thought 
nitrous  oxide  the  safer  and  pleasanter  of  the  two,  and  also  more 
easy  to  inhale.^  In  the  essay  in  which  your  son  first  describes  the 
inhalation  of  sulphuric  ether  in  surgery,  he  points  out  its  similarity 

^ Of  course,  unaware  of  the  comparative  perfection  to  whicli  Dr.  Horace 
■Wells’s  method  of  inducing  brief  surgical  ansestliesia  might  yet  be  brought,  the 
Select  Committee  of  the  House  of  Eepresentatives  of  the  United  States,  in  1852, 
report  so  far  against  the  practical  utility  and  success  of  Dr.  H.  Wells’s  claims  ; 
but  they  add,  “ He  had  the  merit  of  attempting  to  carry  out  practically  the  idea 
suggested  by  Sir  Humphry  Davy  of  rendering  (by  the  influence  of  nitrous  oxide 
gas)  a patient  insensible  to  pain  in  a surgical  operation.  He  has  also  (they  add) 
undoubtedly  the  merit  of  having  contributed  something  in  directing  the  mind  of 
Dr.  Morton  to  the  subject.” — (See  Official  Documents^  pp.  13  and  16.) 

2 Official  Documents,  pp.  26,  27,  and  43 ; Appendix,  pp.  87,  111. 

^ It  is  unnecessary  to  enter  here  into  the  discussion  whether  Dr.  Marcy  of 
Hartford,  in  1844  or  1845,  removed,  without  pain,  a tumour  about  the  size  of  a 
walnut  from  the  head  of  a young  man  who  was  at  the  ftoie  ansesthetised  by  the 
vapour  of  sulphuric  ether  (see  volume  of  Official  Documents,  p.  27,  and  Appendix, 
p.  132,  etc.)  If  so,  he  forestalled  the  use  of  sulphuric  ether  at  Boston  as  an 
ansesthetic  in  surgical  operations.  But  his  experiment  was  so  far  sterile,  as  the 
employment  of  sulphuric  ether  in  surgery  did  not  spread  from  that  point. 


MODERN  HISTORY. 


31 


to  nitrous  oxide. i “ Ether  inhaled  in  vapour,”  he  says,  “ is  well 
known  to  produce  symptoms  similar  to  those  produced  by  the 
nitrous  oxide  ” (see  Paper  read  before  Boston  Society  of  Medical 
Improvement,  3d  November  1846).  Dr.  Horace  Wells  had  the  idea 
suggested  to  his  mind  one  day  (lOth  December  1844)  that  the  in- 
halation of  nitrous  oxide  gas  would  prove  an  amesthetic  in  tooth- 
drawing, and  he  had  it  proved  and  verified  the  next  day  (11th 
December)  on  his  own  person.  But  the  step  from  using  nitrous 
oxide  gas  to  using  sulphuric  ether  vapour  was  slower  and  yet  greater 
and  more  momentous  in  its  results.  Dr.  Morton,  who,  as  his  friend 
and  old  partner,  assisted  at  Dr.  Wells’s  experiment  at  Boston,  no 
doubt  knew  all  the  results  obtained  at  Hartford,  where  he  twice 
visited  Dr.  Wells  after  1844  ; and  he  evidently,  betimes,  got  the 
idea  or  speculation  into  his  mind  that  sulphuric  ether  might  prove 
successful.  From  a difterent  line  of  observation.  Professor  Charles 
Jackson  was  led  to  the  entertainment  of  the  same  speculation. 
Assisted,  apparently,  by  one  or  two  hints  from  Dr.  Jackson  regard- 
ing the  pure  quality  of  the  ether,  or,  possibly,  its  easiest  mode  of 
exhibition.  Dr.  Morton  verified  the  speculation  on  tlie  30th  Septem- 
ber 1846,  by  operating  on  Eben  Frost,  and  fixed  that  date  as  an 
era  in  science. 

III.  ETHERISATION,  OR  ANAESTHESIA,  IN  MIDWIFERY. 

The  first  operations  under  anaesthetic  inhalations  in  America 
occurred,  therefore,  as  we  have  seen  in  the  last  section,  at  Hartford, 
and  not  at  Boston.  In  Hartford  it  was  effected  by  an  anaesthetic 
gas,  long  before  suggested  by  Sir  Humphry  Davy.  But  at  Boston 
you  at  first  retarded,  for  a time,  the  whole  progress  of  anaesthesia, 
by  rejecting  the  evidence  of  it  offered  you  by  Dr.  Horace  Wells. 
For,  to  quote  the  words  of  Dr.  Biggs,  “ there  (in  your  school)  he  met 
with  a reception  so  cold  that,  after  a single  imperfect  trial  of  the 
gas,  amidst  the  sneers  of  those  around  him,  he  left  Boston  in  disgust, 
and  sick  at  heart  at  the  unfair  disposition  manifested  towards  him.” 
Besides  erring  in  this  direction,  you  must  permit  me  to  add  that  in 

1 In  the  volume  of  Official  Documents,  p.  372,  there  is  one  case  entered,  sug- 
gestive of  the  applicability  of  artificial  anaesthesia  from  breathing  sulphuric  ether 
quite  similar  to  Colonel  Cooley’s  experience  with  regard  to  nitrous  oxide.  “A 
young  gentleman,  ten  years  since,  who  is  now  a physician,  was  inhaling  ether  for 
amusement,  as  was  the  custom  at  Harvard  College.  He  took  enough  to  make 
him  so  insensible  that  he  fell  upon  the  floor.  In  falling  he  cut  his  head  badly.  On 
recovering  he  was  unaware  that  he  had  injured  himself  at  all.” 


32 


HISTORY  OF  ANESTHESIA. 


my  opinion  some  of  the  Boston  physicians  have  also  erred  in  quite 
an  opposite  direction.  For,  after  once  making  the  discovery  of  the 
superinduction  of  ansesthesia  by  sulphuric  ether,  you  seem  inclined 
to  hold  that  the  subsequent  merit  of  everything  connected  with 
etherisation  belongs  to  Boston,  and  to  Boston  exclusively. 

The  object  of  your  first  article  on  the  present  subject  was  to 
show  that,  because  when  I received  the  burghership  of  Edinburgh, 
I omitted  to  allude  to  the  previous  use  of  anaesthetics  at  Hartford 
and  Boston,  I was  therefore  deliberately  guilty  of  trying  to  appro- 
priate what  belonged  to  my  American  brethren.  In  my  reply  to 
you,  whilst  showing  that  I was  entirely  guiltless  of  any  such  appro- 
priation in  thought  or  in  word,  I pointed  out  that,  strangely  enough, 
you  yourself  were  in  the  same  article  openly  and  flagrantly  guilty  of 
the  unprofessional  misdemeanour  of  which  you  accused  me  ; for,  in 
claiming,  as  you  there  did,  for  Boston  the  introduction  of  anaesthetic 
inhalations  in  obstetrical  practice,  you  attempted  to  annex  and  appro- 
priate to  your  country  what  most  indubitably  belonged  to  mine. 

In  your  last  letter  you  begrudgingly  state  to  me,  “ I do  not  now 
question  that  you  were  the  first  to  use  ether  in  labour ; ” and  then 
you  superciliously  add,  “ but  who  first  introduced  anaesthetics  in 
obstetrical  practice  is  a matter  of  limited  importance.’'  According 
to  the  testimony,  however,  of  our  late  mutual  friend.  Sir  John  Forbes, 
the  application  of  anaesthetics  to  midwifery  involved  many  more 
difficult  and  delicate  problems  than  its  mere  application  to  dentistry 
and  surgery.  New  rules  required  to  be  established  for  its  use- — the 
time  during  which  it  could  be  given  ascertained — its  effects  upon  the 
action  of  the  uterus,  upon  the  state  of  the  child,  and  upon  the  par- 
turient and  puerperal  state  of  the  mother,  etc.,  all  required  to  be 
accurately  studied.  Would  it  increase  or  diminish  the  tendency 
to  convulsions,  hemorrhage,  and  various  other  complications  ? 
Moral  and  religious  questions  also  came  to  be  involved,  and 
required  to  be  duly  answered.  The  Boston  patent  for  the  use  of 
sulphuric  ether  taken  out  by  Drs.  Morton  and  Jackson,  did  not,  I 
believe,  include  its  employment  in  midwifery ; and  your  son.  Dr. 
Henry  Bigelow,  weeks  after  its  use  was  first  begun,  deemed  it  only 
“ adapted  to  operations  which  were  brief  in  their  duration,  whatever 
be  their  severity.  Of  these  the  two  most  striking  perhaps  are  ampu- 
tations and  the  extraction  of  teeth This  was  published  in  Novem- 

^ See  the  paper  which  he  read  five  or  six  weeks  after  the  introduction  of  sul- 
phuric ether  before  the  Boston  Society  of  Medical  Improvement,  as  cited  in  Brook’s 
Essay  on  the  Vapour  of  Sulphuric  Ether,  page  30. 


MODERN  HISTORY. 


33 


her.  When  I saw  Mr.  Liston  in  London,  during  the  following 
Christmas  holidays,  he  ex2)ressed  to  me  the  opinion  that  the  new 
anaesthetic  would  be  of  special  use  to  him, — who  was  so  swift  an 
operator, — as  he  thought,  like  Dr.  Bigelow,  it  could  only  be  used 
for  a brief  time.  I went  back,  however,  from  this  London  visit  to 
Edinburgh,  bent  on  testing  its  applicability  to  midwifery,  and  found 
that  it  could  be  safely  used  for  hours,  etc. 

But  is  its  application  to  midwifery  of  “ limited  importance,”  as 
now  in  the  fervour  of  disputation  you  seem  anxious  to  affirm  1 Your 
words  in  your  first  article  regarding  the  commencement  of  anaes- 
thetics in  Boston  are  these  : — That  anaesthetic  inhalation  “ began  in 
this  country,  and  was  first  used  in  the  extraction  of  teeth,  and  after- 
wards [2]  in  capital  operations  in  the  Massachusetts  General  Hospi- 
tal ; and  [3]  in  obstetrical  practice.”  You  adduce  thus  three  kinds 
of  practice  in  which  it  was  used  in  Boston — namely  (1)  dentistry ; 
(2)  surgery ; and  (3)  midwifery.  You  have  omitted  medicine,  pro- 
bably because  you  well  knew  the  employment  of  the  inhalation  of 
sulphuric  ether  had  been  introduced  (as  we  have  seen  in  a previous 
part  of  this  letter)  into  medical  practice  by  Dr.  Pearson  half-a- 
century  before.  Holding,  as  you  now  affect  to  declare,  that  the  use 
of  anaesthetics  in  obstetrical  practice  is  a matter  of  limited  import- 
ance, upon  what  ground,  may  I venture  to  ask,  did  you,  only  two 
or  three  months  ago,  in  your  first  attack,  adduce  its  application  to 
midwifery  as  one  of  its  three  chief  applications  ] Further,  among 
these  three  chief  applications,  may  I ask  you,  in  all  honour  and 
honesty,  is  its  use  not,. — even  in  your  opinion, — a matter  of  infinitely 
less  importance  in  dentistry  than  in  midwifery  1 Of  the  relative 
value  of  any  new  practice,  such  as  artificial  ansesthesia,  we  are  bound 
to  judge  by  its  utility,  not  in  any  specialised  practice,  as  that  of  a 
surgical  hospital,  but  in  the  general  practice  of  the  general  practi- 
tioner. Now  most  general  practitioners  have  20  or  30  cases  at  least 
of  labour  in  which  they  may  employ  anaesthetics  for  every  one  case 
of  surgery  in  which  its  use  could  be  adopted  by  them ; surgical  cases 
being  rare,  and  obstetrical  cases  common,  in  general  practice.  You 
practise,  and  have,  I believe,  all  along  practised,  chiefly  as  a physi- 
cian, and  are  hence,  perhaps,  no  good  judge  in  the  matter ; but  let 
me  extract  for  you  from  the  volume  of  Official  Documents  published 
by  your  townsman  Dr.  Morton,  the  opinions  of  one  or  two  general 
practitioners  on  the  subject.  “ It  is,”  says  Dr.  Appleton,  “ in  obstet- 
ric practice  that  I have  most  frecpiently  used  these  most  valuable 
agents,  and  I regard  their  usefulness  in  this  relation  as  among  the 


34 


HISTORY  OF  ANAESTHESIA. 


mod  valuable  results  of  their  discovery.”  “ In  private  practice,” 
writes  Dr.  Ellis,  “ its  mod  happy  and  beneficial  effect  is  in  obstetrics 
its  benefit,  if  in  no  other,  in  this  class  of  cases  alone  is 
the  greatest  discovery  in  any  age  of  the  world  for  the  relief  of  suffer- 
ing humanity.”^ 

You  profess  to  deem  it  a “ matter  of  limited  importance  ” who 
first  introduced  anaesthetics  into  midwifery.  Perhaps  it  is  so.  But 
you  will  excuse  me  adding  that  at  the  time  of  the  first  application  of 
anaesthesia  to  obstetrical  practice — amidst  the  hundreds  and  thou- 
sands of  practitioners  Avho  were  then  engaged  in  midwifery  in  the 
old  and  the  new  world — I happened  to  be  the  first  who  took  up  the 
subject  and  worked  put  most  of  the  problems  connected  with  it. 
Any  one  of  these  hundreds  and  thousands  might  certainly  have  done 
the  same,  but  did  not  do  it. 

Let  me  here  add  that  I would  not  have  dwelt  thus  long  upon 
the  applicacion  of  anaesthetics  to  midwifery,  did  I not  feel  compelled 
to  add  that  other  of  your  medical  townsmen  have  seemed  quietly  on 
this  head  to  have  tried,  like  you  also,  to  appropriate  to  Boston  what 
belongs  to  Edinburgh.  Thus  Dr.  A.  Gould,  in  his  official  deposition 
in  1852,  speaks  of  “the  first  administration  of  sulphuric  ether  in 
obstetrics  by  Dr.  N.  C.  Keep,”^  of  Boston,  as  “a  similar  step  in  the 
discovery  ” as  anaesthesia  in  dentistry  and  surgery.  In  my  former 
letter,  however,  to  you,  I showed  you  that  Dr.  Keep’s  case,  here 
alluded  to  by  Dr.  Gould,  did  not  occur  in  Boston  till  weeks  and 
months  after  the  practice  of  anaesthesia  in  obstetrics  had  been  fully 
studied  and  established  in  Edinburgh.  Besides,  I find  now,  on  look- 
ing over  the  large  volume  published  on  Etherisation  in  Midwifery^ 
by  my  friend,  and  your  townsman.  Dr.  Channing,  that — avoiding  all 
allusion  to  the  midwifery  cases  reported,  and  the  papers  published 
upon  etherisation  in  midwifery,  in  Edinburgh,  weeks  previously  to 
the  occurrence  of  Dr.  Keep’s  case  in  Boston  — he  speaks  also  of 
Dr.  Keep’s  as  if  it  were  the  first  instance  in  which  ether  had  been 
employed  in  obstetrics.  But  this,  perhaps,  is  merely  an  omission, 
as  in  a holograph  inscription  of  his  volume  to  me,  Dr.  Channing  duly 

^ Official  Documents,  pp.  180-182. 

2 Dr.  Keep’s  case  happens  to  be  described  by  Dr.  Channing  in  such  words  as 
to  leave  it  equivocal  whether  or  not  it  was  the  first  obstetric  instance  in  which 
sulphuric  ether  was  given  in  Boston  or  America  only,  or  in  the  world.  Dr. 
Channing’s  account  of  it  is  as  follows: — “The  anaesthetic  power  of  sulphuric 
ether,  when  inhaled,  was  first  used  in  childbirth  in  this  city,  in  a case  of  natural 
labour,  on  the  7th  April  1847,  by  Dr.  N.  C.  Keep,  and  was  successful.” — {Etlieri- 
sation  in  Chilclhirth,  by  Channing,  p.  26. ) 


MODERN  HISTORY. 


35 


acknowledges  that  I was  the  first  to  introduce  ansesthetics  into 
obstetrical  practice  ; and,  in  the  dedication  of  his  work,  he  speaks, 
let  me  add,  of  midwifery  as  being  a department  which  has  derived 
special  and  vast  benefit”  from  the  application  of  anjesthetics. 

According  to  your  reasoning  (?)  in  the  case  of  Sir  Humphry 
Davy,  that  great  philosopher  “ must  be  exonerated  from  all  practical 
knowledge  of  anaesthetic  inhalation ; otherwise  he  is  chargeable 
with  all  the  tortures  of  amputation  and  lithotomy”  which  have 
taken  place  from  his  time  till  the  end  of  1846.  According  to  the 
same  ratiocination,  were  not  you  and  the  other  accoucheurs  of 
Boston  chargeable  with  all  the  tortures  of  childbirth  and  parturition 
borne  by  the  female  population  of  that  city  for  months  onwards 
after  October  1846  ; or,  till  the  knowledge  of  the  mode  of  relieving 
them  from  these  tortures  was  sent  out  from  Edinburgh — seeing  the 
use  of  ether  in  labour  was  a matter  of  limited  importance,  and  could 
and  should  have  been  at  once  discovered  and  applied  in  your  city, 
and  not  in  Europe  ? 

IV.  ALLEGED  NEGLECT  OF  AMERICAN  CLAIMS  IN  WRITING  A 
SKETCH  OF  THE  HISTORY  OF  ANAESTHETICS. 

The  chief  or  only  subject  of  your  attack  upon  me  in  your  first 
article,  was  the  frivolous  allegation  that,  when  last  year  I received 
the  honorary  burgess-ship  of  Edinburgh,  and  when  I had  to  speak 
on  various  and  different  topics,  I omitted  to  do  justice  to  your  city 
and  to  America,  by  omitting  to  talk  of  the  discovery  of  sulphuric 
ether  as  an  ansesthetic  when  I was  called  upon  to  answer  an  obser- 
vation or  two  of  the  Lord  Provost’s  on  chloroform.^ 

^ Lest  there  be  any  mistake  regarding  the  grounds  or  supposed  grounds  of  all 
the  war  wdiich  you  have  tried  to  stir  up  against  me,  let  me  here  cite  in  full  the 
Lord  Provost’s  remarks  on  chloroform,  and  my  reply  to  them.  Tlie  Lord  Provost, 
let  me  state,  was  one  of  the  most  intelligent  and  intellectual  men  of  the  age, 
William  Chambers,  Esq.,  the  well-known  author  and  publisher.  His  address  to 
me  in  presenting  the  burgess  ticket  Avas  spoken  extempore,  and  I find  that  his 
words  on  chloroform  are  someAvhat  dilferently  reported  in  our  three  morning  jour- 
nals. The  version  most  favourable  for  you  is  the  one  you  select — the  Daily 
Review — and  is  as  follows  : — “I  Avill  not  dwell  on  what  you  have  accomplished  in 
medical  science.  I will  only  allude  to  your  discovery — the  greatest  of  all  dis- 
coveries in  modern  times — of  the  application  of  chloroform  in  the  assuagement  of 
liuman  suffering.  That  was  a great  gift  to  mankind  at  large,  and  it  well  befits 
us,  the  Corporation  of  Edinburgh,  to  mark  our  sense  of  the  great  act  of  beneficence 
on  your  part  by  this  small  compliment.”  His  Lordship  subsequently  alluded  to 
my  writings  on  Acupressure,  Hospitalism,  etc.  etc. 

With  regard  to  the  observations  on  Chloroform,  I replied  in  the  two  following 
sentences  : — “You  adverted  to  the  discovery  of  antesthetic  effects  of  chloroform. 


36 


HISTORY  OF  ANESTHESIA. 


In  your  last  letter,  following  out  the  same  jealous  strain  of  com- 
plaint, you  argue  that,  besides  the  alleged  omission  in  an  impromptu 
speech,  I was  guilt}^,  in  an  article  which  I had  calmly  written  upon 
chloroform  in  the  Encyclopcedia  Britannica^  of  not  doing  “ justice  to 
the  great  American  discovery.”  In  that  article,  after  defining 
chloroform  and  stating  its  composition,  modes  of  preparation,  physi- 
cal, chemical,  and  physiological  properties,  I have  described  at  length 
the  various  therapeutic  uses  to  which  it,  and  consequently  any  otlier 
similar  anaesthetic,  could  be  applied  in  surgery,  in  midwifery,  in  medi- 
cine, and  in  medical  jurisprudence  ; and  ultimately  I have  occupied 
the  last  three  columns  of  the  article  by  a brief  historical  sketch  of 
the  various  anaesthetic  agents  which  have  been  used  previously  to  the 
introduction  of  chloroform.  And  this  historical  sketch  is  the  special 
object  of  your  new  attack. 

In  giving,  in  my  lectures  and  otherwise,  a history  of  anaesthetics, 
I have  sometimes  traced  them  from  the  earliest  known  periods 
downwards  to  the  present  day  ; but  more  frequently  I have  followed 
the  inverse  order,  because  I have  found  it  more  instructive  and  inter- 
esting— viz.  that  of  tracing  them  gradually  backwards  from  their  most 
recent  to  their  most  ancient  form.  I have  followed  this  last  method 
in  the  said  article  in  the  Encyclopcedia  Britannica,  and  have  hence 
first  mentioned  chloroform  as  then  the  most  recent  anaesthetic  in  the 
two  following  lines  : — “ The  vapour  of  chloroform  was  first  proposed 
by  Dr.  Simpson  as  an  anaesthetic  agent  in  1847.” 

I then,  after  these  two  lines,  give  about  twenty  lines  to  sulphuric 
ether,  beginning  thus : — “ For  a year  previous  the  vapour  of  sul- 
phuric ether  had  been  used  to  a considerable  extent  both  in  America 
and  Europe,  for  the  purpose  of  inducing  insensibility  to  pain  in 
surgical  operations.  It  was  first  practically  adopted  for  this  purpose 
in  1846  by  Dr.  Morton,  a dentist  at  Boston,  in  America.  Subse- 
quently Dr.  Charles  T.  Jackson  of  that  city  claimed  the  right  of 
having  suggested  to  Dr.  Morton  sulphuric  ether  as  an  a^ent  capable 
of  producing  insensibility  to  pain.  But  the  power  of  producing  by 

Perhaps  you  will  allow  me  to  state  that  there  are  various  manufactories  of  it  in 
Great  Britain,  and  that  a single  one  of  these,  located  in  Edinburgh,  makes  as 
many  as  eight  thousand  doses  a-day,  or  between  two  million  and  three  million  of 
doses  every  j’^ear — evidence  to  what  a great  extent  the  practice  is  now  carried  of 
wrapping  men,  women,  and  children  in  a painless  sleep  during  some  of  the  most 
trying  moments  and  hours  of  human  existence  ; and  especially  when  our  frail 
brother-man  is  laid  upon  the  operating  table,  and  subjected  to  the  tortures  of  the 
surgeon’s  knives  and  scalpels,  his  saws  and  his  cauteries.” — (See  Journal  of  the 
Gynxcological  Society  of  Boston,  No.  C,  p.  370.) 


MODERN  HISTORY. 


37 


the  vapour  of  sulphuric  etlier  an  insensibility  exactly  like  that  pro- 
duced by  the  inhalation  of  nitrous  oxide  gas,  had  been  long  pre^dously 
known,”  and  so  on  through  its  history.^  Thirdly,  I allude  to  car- 
bonic acid  as  suggested  by  Dr.  Hickman  in  1828  ; fourthly,  to  nitrous 
oxide  gas  as  hinted  at  by  Davy  in  1800  ; fifthly,  to  compression  of 
the  nerves  as  used  by  Dr.  Moore  in  1784  ; sixthly,  to  compression  of 
the  carotids  as  suggested  by  Yalverdi  and  others  in  the  sixteenth 
century  ; seventhly,  to  the  fumes  and  extracts  of  mandragora,  Indian 
hemp,  and  other  soporific  drugs,  as  practised  by  mediaeval  and 
ancient  Eoman  and  Greek  surgeons. 

Now  comes  your  strong  and  strange  accusation  or  accusations. 
For  first  you  hold,  as  far  as  I understand  you,  that  the  article  was 
written  for  my  “ self-exaltation,”  or  to  quote  your  own  words,  “ in 
favour  of  the  self- exaltation  of  the  writer.”  Of  any  such  object  I 
know  and  feel  myself  to  have  been  utterly  guiltless,  either  in  this  or 
any  other  of  my  writings.  In  the  whole  course  of  this  long  encyclo- 
paedic article  upon  chloroform,  if  my  object  had  been  “ self-exalt- 
ation,” I might  not  unjustly  have  connected  my  name  witli  several 
of  the  original  suggestions  and  practices  stated  in  the  article ; but  I 
have  mentioned  my  name  only  once,  and  that  in  the  brief  historical 
sentence  already  quoted,  and  when  (I  appeal  to  yourself  or  any 
honourable  man)  such  mention  was  utterly  unavoidable  for  the  sake 
of  simple  historical  accuracy,  all  such  history  inevitably  iiwolving  an 
enumeration  of  names. 

But  then  comes  your  other  accusation,  that  in  enumerating  the 
different  methods  of  producing  anaesthesia  I have  adduced  chloro- 
form ^7*5^,  sulphuric  ether  second,  carbonic  acid  third,  nitrous  oxide 
fourth,  etc.,  to  “cover” — to  use  your  own  reprehensible  words — 
“ this  inversion  of  historical  order  in  favour  of  the  self-exaltation  of 
the  writer  . . . who  availed  himself  of  this  opportunity  prin- 

cipally to  place  himself  conspicuously  in  the  foreground.” 

Believe  me,  I feel  difficulty  in  commenting  upon  these  criticisms 

^ You  underscore  the  expression  used  “to  a considerable  extent,”  probably 
with  a view  of  indicating  that  that  is  doubtful  ; but  such,  I believe,  was  the  fact 
here  and  elsewhere  in  the  first  year  of  etherisation.  In  the  Edinburgh  Medical 
Journal  for  September  1847,  I find  it  stated  by  me  (p.  153)  that,  “ during  the  last 
six  months  etherisation  has  been  used  to  a considerable  extent  in  British  surgery.” 
The  Editor  of  the  same  journal,  in  his  December  number — chloroform  having 
been  introduced  in  the  interval — observes,  “In  Edinburgh  it  (chloroform)  has 
been  used  publicly  by  all  the  surgeons  of  the  Royal  Infirmary  [they  had  not  all 
used  ether],  and  its  employment  in  midwifery  practice  is  almost  universiil. 
Ether,”  he  adds,  “has  almost  been  abandoned”  (p.  456). 


38 


HISTORY  OF  AN.FSTHESIA. 


of  yours ; they  are  essentially  so  groundless  and  absurd  ; and  I 
know  them  in  my  own  heart  to  he  so  utterly  untrue.  If  an 
American  or  English  schoolboy  were  asked  to  give  a retrograde 
chronological  list  of  the  Presidents  of  the  United  States,  or  the 
Sovereigns  of  England,  from  the  present  time  to  the  commencement 
of  this  century,  would  he  not  begin  with  General  Grant  and  Queen 
Victoria  ? According  to  your  logic,  however,  that  would  imply 
“self-exaltation”  on  the  part  of  the  pupil ; and  to  avoid  this  he 
ought  to  commence  with  the  Presidents  Johnson  and  Lincoln,  or 
King  William  the  Fourth.  But  would  not  such  a strange  historical 
obliquity  and  misstatement,  if  unhappily  indulged  in,  bring  down 
condign  punishment  and  contempt  on  the  disciple  1 And  is  there 
not  occasionally  truth  in  the  saying  that  “ sages  sometimes  do  as 
foolish  things  as  schoolboys  ? ” 

If  I had  the  same  history  to  re-write  to-day,  I do  not  know  that 
I would  or  could  v/rite  it  in  any  different  terms,  except  by  pointing 
out  more  distinctly  Dr.  Wells’s  claims,  and  also  Dr.  Jackson’s.  And 
pray  in  what  terms  would  or  could  you  advise  me  that  it  should 
have  been  written,  or  should  be  written  now  / Ought  I to  have 
broken  out  into  some  high-flown  sentence  or  sentences  regarding  the 
history  of  the  ansesthetic  effects  of  sulphuric  ether,  when  I spoke 
secondly  of  that  anaesthetic  1 Would  it  not,  let  me  ask  you,  have 
been  more  natural — for  me  at  least — to  have  done  so  in  speaking  of 
the  history  of  the  anaesthetic  effects  of  chloroform,  instead  of  dismiss- 
ing it  in  the  two  brief  lines  I have  already  quoted  ; seeing,  especially, 
that  I knew  that  it  was  employed  in  hundreds  or  even  thousands  of 
instances  for  every  five  or  ten  in  which  sulphuric  ether  was  used  ? 

I have,  I find,  printed  another  short  epitome  of  the  history  of 
anaesthetics,  but  I am  not  sure  that  it  will  please  you  better.  In  a 
paper  on  Etherisation  in  Surgery,  published  in  September  1847 — 
the  first  of  a series  on  the  subject — I take  occasion  to  speak  of  Dr. 
Morton  of  Boston  as  “ the  gentleman  to  whom  I believe  the  profes- 
sion and  mankind  are  really  and  truly  indebted  for  first  reducing 
into  practice  the  production  of  insensibility  by  ether-inhalation,  with 
the  object  of  annihilating  pain  in  surgical  operations” — language 
stronger,  I think,  than  I have  seen  in  most  American  essays  on  the 
subject.  And  at  the  meeting  of  the  Edinburgh  Medico-Chirurgical 
Society,  on  November  10th  of  the  same  year,  I laid  before  them  a 
paper  termed  “ Historical  Researches  regarding  the  Superinduction 
of  Insensibility  to  Pain  in  Surgical  Operations  ; and  Announcement 
of  a new  Anaesthetic  Agent.”  This  communication  on  the  history 


MODERN  HISTORY. 


39 


of  anaesthetics,  like  that  in  the  Encydopcedia  Britannica,  took  up  the 
subject  in  retrograde  chronological  order,  beginning  with  sulphuric 
ether  fi7'st,  as  chloroform  was  not  known  when  it  was  drawn  up  a 
Aveek  or  two  previously.  In  the  abstract  of  this  historical  paper, 
which  appeared  in  the  Edinlw'gh  Journal^  (it  Avas  never  published 
entire),  I find  that  I traced  out,  at  some  length,  the  chemical  and 
therapeutic  history  of  sulphuric  ether,  and  add  as  folloAvs  : — “ Its 
power  of  producing,  by  inhalation,  effects  like  intoxication,  or  like 
the  influence  of  nitrous  oxide  gas,  he  (Dr.  Simpson)  shoAved  to  have 
been  stated*  by  various  American  authors,  as  by  Professor  Samuel 
Jackson  (1833),  Wood  and  Bache  (1834),  Miller  (1846),  before  it  Avas 
so  fortunately  adopted  by  Dr.  Morton  as  an  anfesthetic  agent.  His 
belief  w'as,  that  Professor  Charles  Jackson  improperly  claimed  the 
merit  pertaining  to  its  recent  happy  application  to  surgery,  etc. 
Perhaps  the  idea  of  relieving  patients  from  the  pains  of  surgery  by 
some  such  means,  or  rather,  the  restoration  of  that  idea  in  recent 
times  (for  it  Avas  an  old  one),  belonged  justly  to  Horace  Wells.” 
From  the  abstract  of  this  paper  it  appears  that  I Avent  chrono- 
logically backwards,  through  various  old  anaesthetic  vapours  and 
measures,  to  the  use  of  the  fumes  of  Indian  hemp  in  the  time  of 
Herodotus.  I then  took  up  the  last  or  second  part  of  the  paper, 
and  shoAved  the  Society  the  neAvly-discovered  anaesthetic,  chloroform, 
and  its  effects. 

At  the  time  at  Avhich  this  paper  Avas  read,  Ave  had,  Avith  almost 
every  mail  from  America,  statements  and  counter-statements  sent 
as  to  Avho  Avas  the  rightful  claimant  for  the  discovery  of  anaethesia 
Avith  sulphuric  ether ; and  Avhat  Avas  conceived  to  be  true  the  one 
month,  was  apt  to  be  upset  the  next.  In  none  of  these  statements 
have  I,  I think,  done  sufficient  justice  to  the  claims  of  Professor 
Charles  T.  Jackson,  for  I now  believe  he  had  more  merit  in  the 
discovery  than  formerly  I felt  inclined  to  attribute  to  him,  since  I 
have  latterly  looked  over  the  large  volume  of  Offidal  Documents  on 
the  matter,  presented  to  the  “ Select  Committee  appointed  by  the 
Senate  of  the  United  States.”  He  held  the  idea  that  sulphuric 
ether  A^apour  might  anaesthetise  a patient  for  an  operation,  though 
he  had  not  reduced  in  any  Avay  that  idea  to  practice,  and  at  first 
seemed  afraid  of  the  possible  results  of  Dr.  Morton’s  experiments,^ 
Avhile  he  avoided  Avitnessing  for  results. 

^ I have  seen  this  epitome  repeatedly  cited,  at  pretty  full  length,  in  American 
essays  on  anaesthetics — sometimes  with,  sometimes  without^  acknowledgment. 

2 OyiciaZ  Dfu'nmients  pp.  352  and  446. 

59 


40 


HISTORY  OF  ANAESTHESIA. 


If  we  try  to  put  into  a summarised  form  the  data*  which  we 
have  been  discussing  regarding  the  introduction  of  anaesthesia  in 
America  and  this  country,  it  appears  to  me  that  we  might  correctly 
state  the  whole  matter  as  follows  : — 

1.  That  on  the  11th  December  1844,  Dr.  Wells  had,  at  Hart- 
ford, by  his  own  desire  and  suggestion,  one  of  his  upper  molar  teeth 
extracted  without  any  pain,  in  consequence  of  his  having  deeply 
breathed  nitrous  oxide  gas  for  the  purpose,  as  suggested  nearlj^  half- 
a-century  before  by  Sir  Humphry  Davy. 

2.  That  after  having  with  others  proved,  in  a limited  series  of 
cases,  the  anaesthetic  powers  of  nitrous  oxide  gas.  Dr.  Wells  pro- 
ceeded to  Boston  to  lay  his  discovery  before  the  Medical  School  and 
Hospital  there,  but  was  unsuccessful  in  the  single  attempt  which  he 
made,  in  consequence  of  the  gas-bag  being  removed  too  soon,  and 
that  he  was  hooted  away  by  his  audience,  as  if  the  whole  matter 
were  an  imposition,  and  was  totally  discouraged. 

3.  That  Dr.  Wells’s  former  pupil  and  partner.  Dr.  Morton  of 
Boston,  was  present  with  Dr.  AVells  when  he  made  his  experiments 
there. 

4.  That  on  the  30th  September  1846,  Dr.  Morton  extracted  a 
tooth  without  any  pain,  whilst  the  patient  was  breathing  sulphuric 
ether,  this  fact  and  discovery  of  itself  making  a NEW  era  in  anaes- 
thetics and  in  surgery. 

5.  That  within  a few  weeks  the  vapour  of  sulphuric  ether  was 
tried  in  a number  of  instances  of  surgical  operations  in  Boston — Dr. 
Morton  being  generally  the  administrator ; — and  ether  vapour  was 
established  as  a successful  anaesthetic  in  dentistry  and  surgery. 

6.  That  in  January,  and  the  subsequent  spring  months  1847, 
the  application  of  sulphuric  ether  as  an  anaesthetic  in  midwifery  was 
introduced,  described  in  our  medical  journals,  and  fully  established 

1 You  must  kindly  excuse  me  if  some  of  the  data  are  not  strictly  accurate  in  every 
point,  as  you  know  how  difficult  it  is  to  make  medical  aphorisms  quite  correct ; 
for  example,  in  the  inscription  which  you  represent  as  cut  upon  the  monument, 
lately  erected  at  Boston,  to  anaesthetics,  namely,  “ To  commemorate  the  discovery 
that  the  inhaling  [the  inhalation]  of  Ether  causes  insensibility  to  pain,  first  proved 
to  the  world  at  the  Massachusetts  General  Hospital,  in  Boston,  October,  a.d. 
1846  there  are,  it  appears,  to  me,  two  errors.  First,  ether  and  sulphuric  etlier 
are  two  terms  not  at  all  synonymous,  and  still  you  have  inserted  the  former  for 
the  latter.  Secondly,  it  is  not  strictly  true  that  the  effects  of  sulphuric  ether  were 
“ first  proved  to  the  world  in  operations  at  the  Massachusetts  General  Hospital.” 
For,  to  cite  the  more  correct  statement  of  Dr.  Channing — “These  operations  were 
Jirsi  performed  in  private  practice,  and  immediately  afterwards  upon  patients  in 
the  Massachusetts  General  Hospital”  (Channing  On  Etherisation,  1848,  p.  26). 


MODERN  HISTORY. 


41 


in  Edinburgh,  before  any  case  with  it  was  tried  in  Boston  or 
America. 

7.  That  on  the  15th  November  1847,  the  anaesthetic  effects  of 
chloroform  were  discovered  in  Edinburgh,  and  that  it  swiftly  super- 
seded in  Scotland  and  elsewhere  the  uise  of  sulphuric  ether,  and 
extended  rapidly  and  greatly  the  practice  of  anaesthesia  in  surgery, 
midwifery,  etc. 

I am  very  sorry  to  have  taken  up  so  much  of  your  time  and  my 
time  with  such  a petty  discussion  as  the  present.  It  has  extended 
to  too  great  a length  ; but  I am  a sad  invalid  just  now,  and  quite 
unable  to  write  with  the  force  and  brevity  required.  With  many 
of  our  profession  in  America  I have  the  honour  of  being  personally 
acquainted,  and  regard  their  friendship  so  very  highly  that  I shall 
not  regret  this  attempt — my  last  perhaps — at  professional  writing  as 
altogether  useless  on  my  part,  if  it  tend  to  fix  my  name  and  memory 
duly  in  their  love  and  esteem. 

Yours  very  truly, 

J.  Y.  Sbipson. 


( 


V 


PAET  II. 

DEFENCES  OF  ANESTHESIA. 


CHAPTER  I. 

ANSWER  TO  THE  RELIGIOUS  OBJECTIONS  ADVANCED  AGAINST  THE 
EMPLOYMENT  OF  ANAESTHETIC  AGENTS  IN  MIDWIFERY  AND 
SURGERY. 

“For  every  creature  of  God  is  good,  and  nothing  to  he  refused,  if  it  be  received 
with  thanksgiving.” — 1st  Timothy  iv.  4. 

“ Therefore  to  him  that  knoweth  to  do  good,  and  doeth  it  not,  to  him  it  is  sin.” — 

James  iv.  17. 

Edinburgh,  Becemher  1847. 

Along  with  many  of  my  professional  brethren  in  Scotland,  and 
perhaps  elsewhere,  I have,  during  the  last  few  months,  often  heard 
patients  and  others  strongly  object  to  the  superinduction  of  anaes- 
thesia in  labour,  by  the  inhalation  of  ether  or  chloroform,  on  the 
assumed  ground  that  an  immunity  from  pain  during  parturition  was 
contrary  to  religion  and  the  express  commands  of  Scripture.  Not 
a few  medical  men  have,  I know,  joined  in  this  same  objection  ; ’ and 
have  refused  to  relieve  their  patients  from  the  agonies  of  child-birth 
on  the  allegation  that  they  believed  that  their  employment  of  suitable 
anaesthetic  means  for  such  a purpose  would  be  iinscriptural  and 
irreligious.  And  I am  informed,  that  in  another  medical  school,  my 
conduct  in  introducing  and  advocating  the  superinduction  of  anaes- 
thesia in  labour  has  been  publicly  denounced  ^ cathedra  as  an 
attempt  to  contravene  the  arrangements  and  decrees  of  Providence, 

^ “ Pain  during  operations  is,  in  tlie  majority  of  cases,  even  desirable  ; its 
prevention  or  annihilation  is,  for  the  most  part,  hazardous  to  the  patient.  In 
the  lying-in  chamber,  nothing  is  more  true  than  this  : pain  is  the  mother’s  safety, 
its  absence  her  destruction.  A^et,  there  are  those  bold  enough  to  administer  the 
vapour  of  ether,  even  at  this  critical  juncture,  forgetting  it  has  been  ordered,  that 
‘in  sorrow  shall  she  bring  forth.’  ” — On  the  “ Injurious  (?)  Effects  of  the  Inhala- 
tion of  Ether,”  in  Edinburgh  Medical  and  Surgical  Journal  for  July  1847,  p.  258. 


RELIGIOUS  OBJECTIONS  ANSWERED. 


43 


hence  reprehensible  and  heretical  in  its  character,  and  anxiously  to 
be  avoided  and  eschewed  by  all  properly  principled  students  and 
practitioners.  I have  been  favoured  with  various  earnest  private 
communications  to  the  same  effect.  Probably,  therefore,  I may  be 
excused  if  I attempt,  however  imperfectly,  to  point  out  what  I con- 
scientiously conceive  to  be  the  errors  and  fallacies  of  those  who  thus 
believe  that  the  practice  in  question  ought  in  any  degree  to  be 
opposed  and  rejected  on  religious  grounds. 

It  is  almost  unnecessary  to  begin  with  premising,  that  those 
who  object  to  the  superinduction  of  anaBsthesia  in  parturition  upon 
religioifs  grounds,  found  their  objections  principally  on  the  words 
of  the  primeval  curse  which  God  pronounced  after  the  temptation 
and  fall  of  our  first  parents.  Few  or  none,  hoAvever,  of  those  who 
have  most  zealously  urged  the  existence  of  this  curse  as  a reason 
against  the  employment  of  anaesthetic  means  in  obstetric  practice, 
have,  I believe,  made  themselves  at  all  intimate  Avith  the  AA^ords  and 
tenor  of  the  curse  itself.  I shall  therefore,  in  the  first  place,  quote 
the  words  of  it  in  full  from  the  third  chapter  of  Genesis,  interpolat- 
ing in  Eoman  letters  the  IlebreAV  originals  of  those  tAvo  nouns 
which  are  the  more  immediate  subjects  of  doubt  and  difference  of 
opinion. 

Genesis,  chap.  iii.  v,  14. — And  the  Lord  God  said  unto  the  serpent,  Because 
thou  hast  done  this,  thou  art  cursed  above  all  cattle,  and  above  every  beast  of  the 
field  ; upon  thy  belly  shalt  thou  go,  and  dust  shalt  thou  eat  all  the  days  of  thy 
life  : 

15.  “And  I Avill  put  enmity  between  thee  and  the  woman,  and  betAveen  thy 
seed  and  her  seed  ; it  shall  bruise  thy  head,  and  thou  shalt  bruise  his  heel. 

16.  “ Unto  the  woman  he  said,  I will  greatly  multiply  thy  sorrow  {HtztzabJion) 
and  thy  conception  : in  sorrow  {’etzehh)  thou  shalt  bring  forth  children  ; and  thy 
desire  shall  be  to  thy  husband,  and  he  shall  rule  over  thee. 

17.  “And  unto  Adam  he  said.  Because  thou  hast  hearkened  unto  tlie  Amice  of 
thy  wife,  and  hast  eaten  of  the  tree,  of  which  I commanded  thee,  saying.  Thou 
shalt  not  eat  of  it : cursed  is  the  ground  for  thy  sake  ; in  sorrow  {’itztzabJion)  shalt 
thou  eat  of  it  all  the  days  of  thy  life  ; 

18.  “Thorns  also  and  thistles  shall  it  bring  forth  to  thee  ; and  thou  shalt  eat 
the  herb  of  the  field. 

19.  “ In  the  sweat  of  thy  face  shalt  thou  eat  bread,  till  thou  return  unto  the 
ground  ; for  out  of  it  wast  thou  taken  : for  dust  thou  art,  and  unto  dust  shalt 
thou  return.” 

In  the  form  of  a few  separate  observations,  I Avill  noAV  add  the 
remarks  and  ansAvers  which  I wish  to  make.  And  I Avould  begin 
by  observing,  that — 

1.  The  primeval  curse  is  triple.  It  contains  a judgment.  First, 
upon  the  serpent  (verses  14,  15);  Secondly,  upon  the  Avoman  (v. 


44 


DEFENCES  OF  ANAESTHESIA. 


16);  and,  Thirdly,  upon  the  ground  for  the  sake  of  the  man  (vv.  17- 
19). — With  the  first  of  these  three  curses — that  on  the  serpent — 
and  its  apparent  permanence  (Isaiah  Ixv.  25),  our  present  inquiry  has 
nothing  to  do.  It  is  enough  for  me  to  remark,  that  the  second  and 
third  curses — on  the  woman  and  on  the  ground — are  evidently,  from 
different  parts  of  the  Holy  Word,  not  immutable.  God  himself,  on 
more  than  5ne  occasion,  promises  the  removal  of  them,  and  in 
general  conjunctly,  to  the  Israelites,  provided  they  would  keep 
their  covenants  and  obey  his  laws.  See,  for  example,  Deuteronomy 
vii.  13,  “I  will  bless  the  fruit  of  thy  womb,  and  the  fruit  of  thy 
land,”  etc. ; xxviii.  4,  “ Blessed  shall  be  the  fruit  of  thy  body,  and 
the  fruit  of  thy  ground,”  etc.  See  also  chap,  xxviii.  11,  etc.  In 
Isaiah  (xxviii.  23-29),  man’s  culture  by  the  plough,  etc.,  of  the 
ground  cursed  by  God,  is  said  to  come  from  the  providence  of  God 
himself  “ For  his  God  doth  instruct  him  to  discretion,  and  doth 
teach  him  ” (v.  26) ; and,  “ This  also  cometh  forth  from  the  Lord 
of  hosts,  which  is  wonderful  in  counsel  and  excellent  in  working” 
(v.  29). 

2.  Those  who,  from  the  terms  of  the  first  curse,  argue  against 
the  superinduction  of  anaesthesia  in  labour,  aver  that  we  are  bound 
to  take  and  act  upon  the  words  of  the  curse  literally,  “ I will 
greatly  multiply  thy  sorrow  and  thy  conception;”  or,  as  Gesenius 
and  other  Hebrew  authorities  state,  that,  being  a case  of  Hendiadys, 
it  may  be  more  correctly  rendered,  “ I will  greatly  multiply  the 
sorrow  of  thy  conception ; ^ in  sorrow  thou  shalt  bring  forth 
children.”  If,  however,  we  are  bound  to  take  this  part  of  the  curse 
literally,  and  act  accordingly,  then  we  are  bound  to  take  and.  act 
also  upon  all  other  parts  of  the  curse  literally.  If  it  is  sinful  to  try 
to  counteract  the  effects  of  this  part  of  it,  referring  to  child-bearing 
women,  it  is  sinful  to  try  to  counteract  the  other  parts  of  it,  regard- 
ing the  state  of  the  ground,  and  the  judgment  upon  man.  The 
agriculturist,  in  pulling  up  “ the  thorns  and  thistles,”  which  the 
earth  was  doomed  to  bear,  so  far  tries  to  counteract  that  part  of  the 
primary  doom  ; and  yet  is  never  looked  upon  as  erring  and  sinning  in 
doing  so.  Or  grant,  as  I have  heard  argued,  that  he  may  be  entitled 
to  pull  up  “ the  thorns  and  thistles,”  because  the  curse  further  implies 
that  he  was  doomed  to  till  the  ground, — still  he  was  doomed  to  till 
it  by  “ the  sweat  of  his  face.”  Now  if,  I repeat,  the  whole  curse  is, 
as  is  averred,  to  be  understood  and  acted  on  literally,  then  man 
must  be  equally  erring  and  sinning,  when,  as  noAV,  instead  of  his 
^ “ Augebo  tibi  molestias.  ” — s Pentateuchm,  p.  38. 


RELIGIOUS  OBJECTIONS  ANSWERED. 


45 


own  sweat  and  personal  exertions,  he  employs  the  horse  and  the  ox 
— water  and  steam  power — sowing,  reaping,  thrashing,  and  grinding 
machines,  etc.,  to  do  this  work  for  him,  and  elaborate  the  “bread” 
which  he  eats.  The  ever  active  intellect  which  God  has  bestowed 
upon  man,  has  urged  him  cn  to  the  discovery  of  these  and  similar 
inventions.  But  if  the  first  curse  must  be  read  and  acted  on 
literally,  it  has  so  far  urged  him  on  to  these  improper  acts  by  which 
he  thus  saves  himself  from  the  effects  of  that  curse.  Nay,  more  ; if 
some  physicians  hold  that  they  feel  conscientiously  constrained  not 
to  relieve  the  agonies  of  a woman  in  childbirth,  because  it  was 
ordained  that  she  should  bring  forth  in  sorrow,  then  they  ought  to 
feel  conscientiously  constrained,  on  the  very  same  grounds,  not  to 
use  their  professional  skill  and  art  to  prevent  man  from  dying ; for 
at  the  same  time  it  was  decreed,  by  the  same  authority,  with  the  • 
same  force,  that  man  should  be  subject  to  death, — “ dust  thou  art, 
and  unto  dust  shalt  thou  return.”  If,  on  the  other  hand,  it  be 
allowed  that  it  is  justifiable  in  the  physician  to  try  to  counteract 
the  effects  of  one  part  of  the  curse,  and  justifiable  in  the  agriculturist 
to  try  to  counteract  the  effects  of  another  part,  it  is  surely  equally 
justifiable  in  the  accoucheur  to  try  to  counteract  the  effects  of  a 
third  part  of  it.  But  if,  on  the  contrary,  it  is  unjustifiable  for  him  to 
follow  out  this  object  of  his  profession,  it  is  equally  unjustifiable  for  the 
physician  and  agriculturist  to  follow  out  the  corresponding  objects  of 
their  professions.  Are  those  who  maintain  the  uncanonical  character 
of  using  human  means  to  contravene  the  pains  of  childbirth  ready, 
then,  to  maintain  that  we  should  not  use  human  means  to  contra- 
vene the  tendency  to  death,  or  to  increase  the  fertility  and  produce 
of  the  ground  except  by  personal  labour,  and  the  actual  “ sweat  ” of 
the  brow  1 To  be  consistent,  they  must  of  necessity  maintain  this 
strange  and  irrational  view  of  man,  and  of  the  duties  and  destinies 
which  God  has  appointed  for  man.  Or,  otherwise,  they  must  own 
that  if  it  is  right  and  meet  in  us  to  exert  the  human  intellect  so 
as  to  ameliorate  the  condition  of  man  from  the  results  of  the 
fall,  it  is  equally  right  and  meet  in  us  to  employ  the  same  means 
to  ameliorate  the  condition  of  woman  from  the  results  of  the  same 
cause. 

3.  But  does  the  word  sorrow  (in  “ sorrow  thou  shalt  bring  forth 
children  ”)  really  mean  physical  and  bodily  loain,  as  is  taken  for 
granted  by  those  who  maintain  the  improper  and  irreligious  charac- 
ter of  any  means  used  to  assuage  and  annul  the  sufferings  of  child- 
birth 1 Now,  the  word  “ sorrow  ” occurs  three  several  times  in  two 


46 


DEFENCES  OF  ANESTHESIA. 


consecutive  verses  of  the  curse  (verses  16  and  17),  The  corre- 
sponding word,  or  rather  words,  in  the  original  Hebrew,  as  I have 
already  shown  when  citing  the  terms  of  the  curse,  are,  'eizebh,  and 
Htztzabhon.  These  nouns  are  both  synonymous  in  meaning  and 
origin,  although  longer  and  shorter  in  form  (like  labour,  laborious- 
ness— pain,  painfulness — in  our  own  language).  All  philologists 
agree  that  they  are  derived  from  the  same  root — viz.  the  verb 
'atzabh.  The  true  and  primitive  meaning  of  a derivative  word  in 
the  Hebrew,  as  in  other  languages,  is  generally  the  best  attained  b}^ 
considering  the  signification  of  the  root  from  which  it^  is  derived. 
The  meaning  of  the  verb  ’dtzabh  (the  root  of  these  nouns)  is  given 
as  follows,  by  Professor  Gesenius,  the  highest  authority,  I believe,  I 
could  quote  on  such  a point.  In  his  Lexicon  he  enters  ^‘'atzabh  1. 

•To  labour,  do  form,  to  fashion.  The  original  idea  (says  he)  is 
perhaps  that  of  cutting,  whether  wood  or  stones.  2.  To  toil  with 
yain,  to  suffer,  to  be  grieved ; used  also  of  the  mind  ” (Tregelles’ 
Translation  of  Gesenius’  Hebrew  and  Chaldee  Lexicon,  p.  dcxlvi). 
Of  the  disputed  nouns,  the  noun  ’etzebh  (“  in  sorrow — 'etzebh — thou 
shalt  bring  forth  children  ”)  is  nearest  in  form,  an<^  hence  in  mean- 
ing, to  the  original  verb-root  ’atzabh — and,  I believe,  no  scholar 
would  deem  it  erroneous  to  affix  to  it  the  same  simple  original 
signification  “ labour,^^  “ toil,'^  without  deeming  it  requisite  to  believe 
that  it  at  all  farther  necessarily  imports  that  the  implied  labour  and 
effort  must  essentially  be  to  such  an  excess  as  actually  to  amount  to 
the  supervention  of  pain  and  agony.  In  fact,  the  Hebrew  word  for 
labour  (in  the  sense  of  work  or  toil)  is  exactly  like  the  English  word 
used  also  to  import  the  act  of  parturition.  Certainly,  the 
greatest  characteristic  of  human  parturition  as  compared  with 
parturition  in  the  lower  animals,  is  the  enormous  amount  of  muscu- 
lar action  and  effort  (labour)  provided  for,  and  usually  required  for 
its  consummation.  The  erect  position  (vultus  ad  sidera  erectus)  of 
the  human  body,  renders  a series  of  peculiar  mechanical  arrange- 
ments and  obstructions  necessary  in  the  human  pelvis,  etc.,  for  the 
prevention  of  abortion  and  premature  labour,  and  for  the  well-being 
of  the  mother  during  pregnancy.  But  these  same  mechanical 
adaptations  and  arrangements  (such  as  the  angle  at  which  the  pelvis 
is  set  to  the  spine, — the  great  difference  in  the  axis  of  the  pelvic 
brim,  cavity,  and  outlet — the  rigidity  of  the  soft  structures,  etc.) 
render  also,  at  last,  the  ultimate  expulsion  of  the  infant  in  labour, 
a far  more  difficult  and  more  prolonged  process  than  in  the  quad- 
ruped, for  instance,  with  its  horizontal  body.  To  overcome  these 


RELIGIOUS  OBJECTIONS  ANSWERED. 


47 


greater  mechanical  obstacles,  the  human  mother  is  provided  with  a 
uterus  immensely  more  muscular  and  energetic  than  that  of  any 
of  the  lower  animals.  The  uterus  of  woman  is  many  times  stronger 
and  more  powerful  than  the  uterus,  for  example,  of  the  cow.  In 
other  words,  I repeat,  the  great  characteristic  of  human  parturition 
is  the  vastly  greater  amount  of  muscular  effort,  toil,  or  labour 
required  for  its  accomplishment.^  The  state  of  anaesthesia  does  not 
withdraw  or  abolish  that  muscular  effort,  toil,  or  labour ; for  if  so, 
it  would  then  stop,  and  arrest  entirely,  the  act  of  parturition  iteelf. 
But  it  removes  the  physical  pain  and  agony  otherwise  attendant  on 
these  muscular  contractions  and  efforts.  It  leaves  the  labour  itself 
(etzehh)  entire.  And  in  relation  to  the  idea  that  the  Hebrew'  noun 
in  the  text  truly  signifies  muscular  toil  and  effort,  and  not  physical 
pain  and  maternal  agony,  it  is  further  highly  important  to  remark, 
that  in  the  very  next  verse  (verse  17) — viz.  in  the  first  part  of  the 
curse  on  man — the  analogous  Hebrew  noun  (itztzabhon),  which  w'e 
translate  by  “ sorrow,”  does  not  in  any  degree  mean  or  imply 
mortal  suffering  or  pain,  but  toil  and  labour.  “ In  sorrow  thou 
shalt  eat  of  it  (the  ground)  all  the  days  of  thy  life.”  Indeed,  the 
very  same  noun  (^itztzabhon),  when  it  occurs  Avith  the  same  meaning, 
and  in  relation  to  the  same  curse  two  chapters  onwards — Genesis  v. 
29 — is,  in  our  version,  rendered  by  the  Avord  “toil,”  and  not 
“ sorrow.”  “ And  he  called  his  name  Hoah  (rest  or  comfort),  say- 
ing, This  same  shall  comfort  us  concerning  our  Avork  or  toil 
i^itztzablwn)  of  our  hands,  because  of  the  ground  Avhich  our  Lord 
hath  cursed.” 

The  Avord  “ sorroAv  ” is  a term  at  once  simple  and  striking,  but, 
at  the  same  time,  very  comprehensive  in  its  signification  ; and  used 
under  various  specific  meanings  in  our  authorised  English  version  of 
the  Bible.  In  the  Old  Testament,  above  tAA^enty  different  terms  or 
nouns  in  the  original  HebreAV  text  are  translated  by  the  single 

^ In  some  of  the  black  tribes  of  the  human  race,  the  muscular  efforts  and 
exertions  of  the  uterus  seem  to  be  accompanied  with  comparatively  little  or  no 
physical  pain — there  is  labour  without  suffering.  But  the  black  woman  was 
cursed  as  well  as  the  white  ; and  surely  it  cannot  be  irreligious  to  reduce  the 
sufferings  of  the  civilised  female  to  the  degree  and  amount  which  nature  has  left 
them  existing  in  the  uncivilised  female  of  our  race.  There,  are  abundance  of 
“maternal  sorrows”  connected  with  children  and  child-bearing  in  civilised 
women,  quite  independently  of  the  actual  agonies  of  parturition.  My  friend  Dr. 
Churchill  of  Dublin,  some  years  ago,  published  a large  octavo  volume  on  the 
affections  'peculiar  to  the  pregnant  and  puerperal  states,  without  at  all  including 
those  observable  during  labour. 


48 


DEFENCES  OF  ANAESTHESIA. 


term  or  noun  “ sorrow  ” in  the  English  text.^  And  perhaps  it  may 
not  be  considered  irrelevant,  if  I remark,  that  the  identical  Hebrew 
noun  ^etzebh,  translated  “ sorrows  ” in  the  16th  verse  (“  in  sorrow — 
'etzebJi — thou  shalt  bring  forth  children  ”),  recurs  in  six,  and  I 
believe  only  in  six,  other  passages  in  the  Old  Testament ; and  in 
not  one  of  these  does  it  certainly  imply  physical  pain.  In  two  of 
these  six  places  it  is  rendered,  in  our  English  version,  by  the  very 
word  “ labour,”  in  the  signification  of  toil  or  work — viz.  in  Prov. 
xiv.  23,  “In  all  labour  (etzebh)  there  is  profit;”  and  Prov.  v.  10, 
“ Lest  thy  labours  ^ (etzebJi)  be  in  the  house  of  a stranger.”  In  one 
passage  it  is  translated  “ anger,”  ® Prov.  xv.  1 — “ Grievous  words  stir 
up  anger  (etzebh).'"  In  another  passage  in  which  it  occurs,  in  Prov. 
X.  22,  it  is  rendered  sorrow,  but  still  in  the  sense  of  toil  and  work 
— “The  blessing  of  the  Lord,  it  maketh  rich,  and  he  addeth  no 
sorrow  (etzebh)  * with  it.”  In  Psalm  cxxvii.  2,  it  is  also,  in  our 
English  version,  translated  “ sorrows  ” — “ It  is  in  vain  for  you  to  rise 
up  early,  to  sit  up  late,  to  eat  the  bread  of  sorrows  (^atzabhim,  the 
plural  of  'etzebh)y^  And,  lastly,  in  Jeremiah  xxii.  28,  the  same 
noun  is  translated  “ idol  ” (a  thing  made,  worked,  or  fashioned) — 
“Is  this  man  Coriah  a despised,  broken  idol  {'etzebh)V' 

The  context,  I repeat,  in  these  six  biblical  passages  in  which 
the  noun  ^etzebh  recurs,  shows  that  in  them  the  word  is  not,  in  any 
respect,  employed  to  designate  the  sensation  of  pain  which  accom- 
panies the  act  of  parturition  in  the  human  female.  And  it  is  surely 
not  an  unfair  or  illegitimate  deduction,  to  infer  that  in  the  only  one 
remaining,  or  seventh  instance  in  which  the  word  occurs  in  the 
Bible — viz.  in  Genesis  hi.  16 — it  would  be  used  in  the  sense  in 
which  it  is  generally  elsewhere  used — of  effort,  toil,  or  labour — and 
not  in  a new  sense,  in  which  it  is  nowhere  else  used — of  the  feeling 
or  perception  of  , excruciating  suffering,  or  bodily  anguish. 

4.  But  that  the  preceding  deduction  is  sound  and  just,  admits 
of  additional,  and  still  stronger,  corroborative  evidence.  In  various 
passages  in  the  Bible,  the  proverbial  agony  and  pain  of  a woman  in 
travail  is  brought  in — and  particularly  in  the  inspired  language  of 
the  Prophets — as  a striking  and  beautiful  simile,  to  mark  the 

^ See  a list  of  these  various  Hebrew  words  which  the  translators  of  the  English 
Bible  have  rendered  by  the  word  “sorrow,”  in  The  Encjlish/man s Hebrew  aiid 
Chaldee  Concordance  of  the  Old  Testament,  p.  1639. 

^ “ Labours,”  t.c.  “ things  done  with  toil.” — Gesenius. 

^ “A  word  pronounced  with  anger — a bitter,  sharp  wor^.” — Gesenius, 

^ That  is,  no  “heavy  and  toilsome  labour.” — Gesenius. 

® “ Bread  obtained  by  toilsome  labours,” — Gesenius. 


RELIGIOUS  OBJECTIONS  ANSWERED. 


49 


greatest  possible  degree  of  anguish  and  suffering.  In  not  one  of  these 
passages,  in  which  the  pure  pain  and  super-sensitive  suffering  of  the 
parturient  mother  are  thus  referred  to,  is  the  word  in  Genesis  iii. 
16 — viz.  the  word  ’etzebh — employed  to  designate  this  feeling  of  pain 
and  suffering.  Two  other  and  totally  different  Hebrew  nouns  are 
used  for  this  purpose  in  the  passages  to  which  I allude.  These  two 
nouns  are  hhil  and  hhehhel.  They  mark  and  designate  the  sensa- 
tions of  agony  accompanying  parturition,  as  contradistinguished 
from  the  muscular  efforts  (or  labour)  (etzehh)  in  which  the  physio- 
logical part  of  the  process -of  the  expulsion  of  the  child  essentially 
consists.  To  illustrate  the  particular  signification  thus  attached  to 
the  words  iihil  and  hhehhel,  as  contradistinguished  from  ’eizehh,  I will 
cite  the  passages  in  which  the  two  former  nouns  are  used.  In  the 
following  instances,  the  noun  hhil  is  translated  “ pain,”  “ pangs,” 
etc. : — Psalm  xlviii.  6,  “Fear  took  hold  uj^on  them  there,  and  pain 
as  of  a woman  in  travail.”  Jeremiah  vi.  24,  “ Anguish  hath  taken 
hold  of  us,  and  pain  as  of  a woman  in  travail.”  Jeremiah  xxii.  23, 
“ When  pangs  come  upon  thee,  the  pain  as  of  a woman  in  travail.” 
See  also  Jeremiah,  1.  43.  Micah,  iv.  9,  “Now  why  dost  thou  cry 
out  aloud  1 is  there  no  king  in  thee  ? is  thy  counsellor  j^erished  ? 
for  pangs  have  taken  thee  as  a woman  in  travail.”  In  the  following 
instances,  the  noun  hhehhel  occurs  in  the  original  Hebrew  with  the 
same  meaning  attached  to  it : — Isaiah  xiii.  8,  “ Pangs  and  sorrow 
shall  take  hold  of  them ; they  shall  be  in  pain  as  a woman  that 

travaileth.”  Isaiah  xxvi.  17,  “Like  as  a woman  with  child,  that 

draweth  near  the  time  of  her  delivery,  is  in  pain  and  crieth  out  in 
her  pangs.”  See  also  Isaiah  Ixvi.  7 ; Jeremiah  xiii.  21,  and  xlix. 

23.  Hosea  xiii.  13,  “The  sorrows  of  a travailing  woman  shall 

come  upon  thee.” 

From  what  I have  stated  under  the  two  jjreceding  heads,  we 
are  then,  I believe,  justly  entitled  to  infer  that  the  Hebrew  term 
which,  in  our  English  translation  of  the  primeval  curse,  is  ren- 
dered “sorrow”  (Grenesis  iii.  16),  principally  signifies  the  severe 
muscular  efforts  and  struggles  of  which  parturition — and  more  par- 
ticularly human  parturition — essentially  consists ; and  does  not 
specially  signify  i\iQ  feelings  or  sensations  of  pain  to  which  these 
muscular  efforts  or  contractions  give  rise.  And,  2.  On  the  other 
hand,  the  feelings  or  sensations  of  excruciating  pain  accompanying 
the  process  of  parturition,  are  designated  throughout  the  Bible  by 
two  Hebrew  words  which  are  entirely  and  essentially  different  from 


50 


DEFENCES  pF  ANAESTHESIA. 


that  term  which  is  translated  “ sorrow,”  in  the  oft-repeated  expres- 
sion— “in  sorrow  thou  shalt  bring  forth  children.” 

5.  But  even  if — contrary  to  what,  I think,  the  whole  philo- 

logical consideration  of  the  very  terms  and  words  of  the  Bible 
shows  to  be  the  case — we  were  to  admit  that  woman  was,  as  the 
results  of  the  j^rimal  curse,  adjudged  to  the  miseries  of  pure  phy- 
sical pain  and  agony  in  parturition,  still,  certainly  under  the 
Christian  dispensation,  the  moral  necessity  of  undergoing  such 
anguish  has  ceased  and  terminated.  Those  who  believe  otherwise, 
must  believe,  in  contradiction  to  the  whole  spirit  and  whole  testi- 
mony of  revealed  truth,  that  the  death  and  sacrifice  of  Christ  was 
not,  as  it  is  everywhere  declared  to  be,  an  all-sufficient  sacrifice  for 
all  the  sins  and  crimes  of  man.  Christ,  the  “ man  of  sorrows,” 
who  “ hath  given  himself  up  for  us  an  offering  and  a sacrifice  to 
God,”  “ surely  hath  borne  our  griefs  and  carried  our  sorrows  ; ” for 
God  “ saw  the  travail  of  his  soul,  and  was  satisfied.”  And  He 
himself  told  and  impressed  on  his  disciples,  that  his  mission  was 
to  introduce  “ mercy,  and  not  sacrifice.”  (See  Matthew  ix.  13; 
xii.  7 ; also  Hos.  vi.  G.)  At  the  end  of  his  commentary  upon  the 
curse  in  the  third  chapter  of  Genesis,  the  sound  aud  excellent 
Matthew  Henry,  in  his  own  quaint,  pithy,  and  zealous  style,  justly 
observes,  “ How  admirably  the  satisfaction  our  Lord  Jesus  Christ 
made  by  his  death  and  sufferings,  answered  the  sentence  here 
passed  upon  our  first  parents.  L,  Did  travailing  jpains  come  in  with 
sin  ? We  read  of  the  ‘ travail  of  Christ’s  soul,’  Isa.  liii.  1 1 : and 
the  pains  of  death  he  was  held  by,  are  called  ud/mi,  Acts  ii.  24 — 
the  ‘ pains  of  a woman  in  travail’  2.  Did  subjection  come  in  with 
sin  ? Christ  was  ‘ made  under  the  law,’  Gal  iv.  4.  3.  Did  the 

curse  come  in  with  sin  ^ Christ  was  made  a ‘ curse  for  us  ; ’ died  a 
‘ cursed  deatli,’  Gal.  hi.  1 3.  4.  Did  thorns  come  in  with  sin  ? He 

was  crowned  with  ‘ thorns  ’ for  us.  5.  Did  sweat  come  in  with  sin  ? 
He  sweat  for  us,  ‘ as  it  had  been  great  drops  of  blood.’  6.  Did 
sorrow  come  in  with  sin  h He  was  ‘a  man  of  sorrows  ; ’ his  soul 
was  in  agony  ‘ exceeding  sorrowful’  7.  Did  death  come  in  with 
sin  ? He  became  ‘ obedient  unto  death.’  Thus  is  the  plaister  as 
wide  as  the  wound.  Blessed  be  God  for  Jesus  Christ.”* 

6.  It  may  not  be  out  of  place  to  remind  those  who  oppose  the 
employment  of  amesthetic  means  in  labour  on  supposed  religious 
grounds,  that  on  the  very  same  grounds  many  discoveries  in  science 
and  art — even  in  the  medical  art — have  been  opposed  upon  their 

^ Exposition  of  the  Books  of  Moses,  p,  19. 


KELIGIOUS  OBJECTIONS  ANSWEKED. 


51 


first  proposition ; and  yet,  now  that  their  first  introduction  is  over, 
and  the  opinions  and  practices  they  inculcate  are  established,  no 
one  would  be  deemed  exactly  rational  who  would  turn  against  the 
present  or  future  continuance  of  their  employment  any  such  improper 
weapon.  I might  adduce  many  instances,  but  one  may  suffice  for 
all.  When  small-pox  inoculation  was  introduced  towards  the  com- 
mencement of  the  last  century,  the  Eev.  Messrs.  Delafaye  and  Massey 
published  sermons  against  the  practice  as  indefensible,  on  religious 
as  well  as  medical  grounds.^  Inoculation  was  declared  a “ dia- 
bolical operation,”  and  a discovery  sent  into  the  world  by  the 
Powers  of  Evil.  And,  again,  when  Dr.  Jenner  introduced  vaccina- 
tion instead  of  small-pox  inoculation,  towards  the  commencement 
of  the  present  century,  theological  reasons  again  were  not  wanting  for 
calling  in  question  the  orthodoxy  of  this  other  new  practice.  “ Small- 
pox,” argued  Dr.  Rowley,  “ is  a visitation  from  God,  and  originates 
in  man,  but  the  cow-pox  is  produced  by  presumptuous,  impious 
man.  The  former,  heaven  ordained  ; the  latter  is  perhaps  a daring 
and  profane  violation  of  our  holy  religion.”  And  he  subsequently 
proposed,  “ whether  vaccination  be  agreeable  to  the  will  and  ordi- 
nances of  God,  as  a question  worthy  of  the  consideration  of  the 
contemplative  and  learned  ministers  of  the  gospel  of  J esus  Christ ; 
and  whether  it  be  impious  and  profane,  thus  to  wrest  out  of  the 
hands  of  the  Almighty  the  divine  dispensation  of  Providence  ! ” * 
“ The  projects  of  these  vaccinators  seem,”  it  was  affirmed,  “ to  bid 
bold  defiance  to  heaven  itself,  even  to  the  will  of  God.”^  “ Provi- 
dence,” reasoned  another  author,  “ never  intended  that  the  vac- 
cine disease  should  affect  the  human  race,  else  ichj  had  it  not,  before 
this  time,  visited  the  inhabitants  of  the  globe.  “ The  law  of  God,” 

^ See  Delafaye’s  sermon  on  “Inoculation  ; an  Indefensible  Practice.” — Mas- 
sey’s “Sermon  against  the  Dangerous  and  Sinful  Practice  of  Inoculation.”  In 
his  admirable  Account  of  the  Inoculation  of  Small -pox  in  Scotland  (1765),  Dr. 
Monro  {primus)  states,  “ The  first  and  most  general  prejudice  against  inoculation 
is  its  being  deemed  a tempting  of  God’s  providence,  and  therefore  a heinous 
crime.” — P.  5.  “Clergymen,”  observes  Dr.  Baron,  in  \\\s.  Life  of  Jenner,  vol.  i. 
p.  231,  “ preached  from  their  pulpits  in  this  style  of  argument,  if  so  it  might  be 
called.  Some  went  so  far  as  to  pronounce  inoculation  an  invention  of  Satan 
himself,  and  its  abettors  were  charged  with  sorcery  and  atheism.”  “These 
things,”  he  adds,  “would  scarcely  obtain  credence,  were  it  not  that  similar  argu- 
ments and  assertions  have  been  employed  against  vaccination  itself.” 

^ Blair’s  Vaccine  Contest,  p.  84. 

® Rowley  on  Cow-pocTc  Inoculation ; with  the  Modes  of  treating  the  Beastly 
new  Diseases  produced  by  it,  p.  9. 


52 


DEFENCES  OF  ANESTHESIA. 


he  continues,  “ prohibits  the  practice  ; the  law  of  man  and  the  law 
of  nature  loudly  exclaim  against  it.”  ‘ 

Such  historical  facts  and  efforts,  and  the  results  in  which  they 
have  invariably  terminated,  are  surely  sufficient  to  make  men 
cautious  and  hesitating  against  always  recklessly  calling  up  again 
the  same  religious,  or  supposed  religious,  arguments  under  the  same 
circumstances.^  Views  and  arguments  of  this  description  against 
every  new  practice  intended  to  increase  the  well-being  and  happiness 
of  mankind,  certainly  are  greatly  more  calculated  to  inflict  damage 
than  benefit  upon  the  interests  of  true  religion. 

Probably  I may  here  be  excused  adding,  that  my  friend  Professor 
Miller  informs  me,  that  when  reluctantly  consenting  to  write  the 
elaborate  article  on  Etherisation,  which  he  afterwards  penned  for 
the  JVorf/i  British  Fceview  (No.  for  May  1847),  he  stated  to  the  late 
Dr.  Chalmers,  who  solicited  him  to  undertake  the  task,  that  if  he 
“ wrote  the  medical.  Dr.  Chalmers  should  himself  write  the  theo- 
logical part.”  Dr.  Chalmers  at  once  professed  that  he  did  not  see 

^ Dr.  Squirrell’s  Preface  to  the  second  edition  of  his  Observations  on  Cow- 
pox,  and  the  dreadful  consequences  of  this  new  Disease,  p.  iv. 

^ Perhaps,  in  the  history  of  misplaced  religious  arguments  against  all  novel 
opinions  and  practices,  none  in  the  retrospect  may  appear  stranger  than  one  that 
has  been  repeatedly  mentioned  to  me  during  the  few  past  months.  Formerly, 
among  my  countrymen,  most  agricultural  operations  were  performed,  as  eom- 
manded  in  the  primeval  curse,  by  personal  exertion,  and  the  “ sweat  of  the  face.” 
Corn,  in  this  way,  was  winnowed  from  the  chaff  by  tossing  it  repeatedly  up  into 
the  air,  upon  broad  shovels,  in  order  that  any  accidental  currents  which  were 
present  might  carry  off  the  lighter  part.  At  last,  however,  about  a century  ago, 
“ fanners,”  or  machinery  made  for  the  production  of  artificial  cxw'venis  to  effect 
the  same  purpose,  were  invented  and  introduced  into  different  parts  of  the  country. 
Some  of  the  more  rigid  sects  of  Dissenters  loudly  declaimed  against  the  employ- 
ment of  any  such  machinery.  “ Winds  (they  argued)  were  raised  by  God  alone, 
and  it  was  irreligious  in  man  to  attempt  to  raise  wind  for  the  aforesaid  purpose 
for  himself,  and  by  efforts  of  his  own.”  Mr.  Gilfillan,  the  well-known  Scottish 
poet,  has  furnished  me  with  evidence  of  one  clergyman  debarring  from  the  com- 
munion of  the  Lord’s  Supper  those  members  of  his  flock  who  thus  irreverently 
used  the  “ Devil’s  wind  ” (as  it  was  termed).  And  such  sentences,  I believe,  were 
not  uncommon  almost  within  the  memory  of  some  aged  members  of  the  present 
generation.  Sir  Walter  Scott,  in  his  Old  Mortality,  introduces  honest  Mause 
Headrigg  as  charging  the  Lady  Margaret  Bellenden  and  the  authorities  at  Tillie- 
tudlem  with  abetting  this  reprehensible  practice.  “And  since  your  leddyship  is 
pleased  to  speak  o’  parting  wi’  us,  I am  free  to  tell  you  a piece  o’  my  mind  in 
another  article.  Your  leddyship  and  the  steward  hae  been  pleased  to  propose  that 
my  son  Caddie  suld  work  in  the  barn  wi’  a new-fangled  machine  for  dighting  the 
corn  frae  the  chaff,  thus  impiously  thwarting  the  will  of  Divine  Providence,  by 
raising  wind  for  your  leddyship’s  ain  particular  use  by  human  art,  instead  of 
soliciting  it  by  prayer,  or  waiting  patiently  for  wdiatever  dispensation  of  wind 
Providence  was  pleased  to  send  upon  the  sheeling  hill.”  (Chap,  vii.) 


RELIGIOUS  OBJECTIONS  ANSWERED. 


53 


any  theological  part  pertaining  to  it.  Mr.  Miller  then  explained  to 
him,  that  some  had  been  urging  objections  against  the  use  of 
anaesthesia  in  midwifery,  on  the  ground  of  it  so  far  improperly  en- 
abling woman  to  avoid  one  part  of  the  primeval  curse.  At  last, 
when  Mr.  Miller  was  enabled  to  convince  him  that  he  was  in  earnest 
in  saying  that  such  ground  had  been  taken.  Dr.  Chalmers  thought 
quietly  for  a minute  or  two,  and  then  added,  that  if  some  “ small 
theologians  ” really  took  such  an  improper  view  o(  the  subject,  he 
would  certainly  advise  Mr.  Miller  not  to  “ heed  them  ” in  his  article. 
Dr.  Chalmers’s  mind  was  not  one  that  could  take  up  or  harbour  the 
extraordinary  idea,  that,  under  the  Christian  dispensation,  the  God 
of  Mercy  should  wish  for,  and  delight  in,  the  sacrifice  of  woman’s 
screams  and  sufferings  in  childbirth.  Perhaps  lie  thought  also,  as  I 
have  heard  other  clergymen  state,  that  if  God  has  beneficently  vouch- 
safed to  us  a means  of  mitigating  the  agonies  of  childbirth,  it  is  His 
evident  intention  that  we  should  employ  these  means.  The  very 
fact  that  we  have  the  power  by  human  measures  to  relieve  the 
maternal  sufferings,  is  in  itself  a sufficient  criterion  that  God  would 
rather  that  these  sufferings  be  relieved  and  removed.  If  He  had 
willed  and  desired  them  not  to  be  averted,  it  would  not  be  possible 
for  man  to  avert  them.  For  while  it  is  our  duty  to  avoid  all  misery 
and  suffering  that  is  avoidable,  it  would  certainly  be  impossible  for 
us  to  eschew  any  that  God  had  permanently  and  irreversibly  decreed 
should  not  be  eschewed. 

7.  I have  heard  objections  urged  against  the  state  of  amnsthesia 
as  a counteraction  to  pain  in  surgery  and  midwifery,  on  other  and 
different  grounds  from  any  I have  yet  noticed — viz.  that  in  superin- 
ducing a temporary  absence  of  corporeal  sensibility,  we  also  super- 
induce, at  the  same  time,  a temporary  absence  of  mental  consciousness. 
And  it  is  argued,  that,  as  medical  men,  we  are  not  entitled  to  put 
the  activity  and  consciousness  of  the  mind  of  any  patient  in  abey- 
ance, for  the  mere  purpose  of  saving  that  patient  from  any  bodily 
pain  or  agony.  Some  medical  men  even  have  gravely  pressed  this 
argument.  But  if  there  were  any  propriety  in  it,  why,  then,  these 
same  medical  men  could  never  have  been  justified  in  doing  what 
they  have  one  and  all  of  them  done  perhaps  hundreds  of  times — 
viz.  exhibit  by  the  mouth,  opium  and  other  narcotics  and  hypnotics 
to  their  patients,  to  mitigate  pain  and  superinduce  anaesthesia  and 
sleep.  There  is  no  greater  impropriety  or  sin  in  producing  sleep 
and  freedom  from  pain  by  exhibiting  a medicine  by  the  mouth  than 
by  exhibiting  it  by  the  lungs.  There  is  less  impropriety  in  the  latter 


54 


DEFENCES  OF  ANAESTHESIA. 


practice  than  in  the  former,  even  according  to  the  very  doctrine  of 
these  opponents.  For  narcotic  or  anaesthetic  agents  which  are 
swallowed,  are  far  more  prolonged  in  their  “ insensihilising  ” action 
upon  both  the  mind  and  body  than  those  that  are  inhaled.  The 
questionable  character  of  the  practice  (supposing  it  for  a moment 
to  be  questionable),  must  be  much  less  when  the  effect  is  short  and 
evanescent,  as  with  ether  and  chloroform  when  respired,  than  when 
it  is  long  and  protracted,  as  with  opium,  morphia,  henbane,  etc., 
when  swallowed.  The  proper  anaesthetic  state  is  one  physiologically 
and  psychically  analogous  to  natural  deep  sleep.  It  is  an  artificial 
deep  sleep.  Those  who  object  and  urge  that  we  should  never  follow 
ourselves,  or  induce  others  to  follow,  the  practice  of  voluntarily 
surrendering  up  our  mental  consciousness  for  a time,  in  order  to 
avoid  any  corporeal  torture  or  agony  that  we  should  otherwise 
endure  during  that  time,  forget  how  often  and  how  long  they  and 
others  are  in  the  habit  of  voluntarily  surrendering  up  their  mental 
consciousness  in  common  sleep,  far,  far  beyond  the  time  required 
merely  for  the  refreshment  and  renovation  of  the  system.  Many 
thus  daily  surrender  their  minds  and  reason  up  for  unnecessary 
hours  to  the  state  of  unconsciousness  existing  in  common  or  natural 
sleep,  without  any  object  except  the  reprehensible  indulgence  of  sloth 
and  indolence  ; and  then  they  turn  round,  and  declaim  against  others 
having  induced  upon  them,  at  some  rare  and  extraordinary  time,  the 
unconsciousness  of  artificial  sleep,  when  there  is  a great  and  laudable 
object  in  view — viz.  the  avoidance  of  excruciating  corporeal  suffer- 
ing, and  the  saving  of  human  life  by  saving  the  human  system  from 
the  shock  and  dangers  accompanying  that  suffering.  Besides,  those 
who  urge,  on  a kind  of  religious  ground,  that  an  artificial  or  anaes- 
thetic state  of  unconsciousness  should  not  be  induced  merely  to  save 
frail  humanity  from  the  miseries  and  tortures  of  bodily  pain,  forget 
that  we  have  the  greatest  of  all  examples  set  before  us  for  following 
out  this  very  principle  of  practice.  I allude  to  that  most  singular 
description  of  the  preliminaries  and  details  of  the  first  surgical 
operation  ever  performed  on  man,  which  is  contained  in  Genesis  ii. 
2 1 : — “ And  the  Lord  God  caused  a deep  sleep  to  fall  upon  Adam  ; 
and  he  slept ; and  he  took  one  of  his  ribs,  and  closed  up  the  flesh 
instead  thereof.”  In  this  remarkable  verse  the  whole  process  of  a 
surgical  operation  is  briefly  detailed.  But  the  passage  is  principally 
striking,  as  affording  evidence  of  our  Creator  himself  using  means  to 
save  poor  human  nature  from  the  unnecessary  endurance  of  physical 
pain.  “ It  ought  to  be  noted  (observes  Calvin  in  his  commentary 


* 


KELIGIOUS  OBJECTIONS  ANSWERED.  55 

on  tins  verse),  that  Adam  was  sunk  into  a profound  sleep,  in  order 
that  he  might  feel  no  pain.”^  In  his  collected  commentaries  on  the 
same  verse,  Pool  quotes  different  authorities  for  the  same  opinion, 
that  this  deep  sleep  was  induced  upon  Adam,  in  order  that  “ he 
might  not  feel  pain  from  the  removal  of  the  rib.”^  And  the  pro- 
fimdity  of  the  sleep,  as  expressed  in  the  Hebrew,  is  also  worthy  of 
note.  For  the  noun  “ tardemah,''  translated  in  our  version  “ deep 
sleep,”  3 signifies,  according  to  all  the  best  Hebrew  scholars,  the 
deepest  form  of  induced  slumber.  In  the  early  and  very  literal 
Greek  translation  which  Aquilla  made  of  the  Bible,  he  renders,  in 
this  passage,  the  Hebrew  word  tardemah  by  the  expressive  Greek 
term  zara^oga,  a term  which  Hippocrates,  Galen,  ^tius,  and  other 
Greek  physicians  used  as  implying  that  state  of  insensibility  and 
total  unconsciousness  which  in  modern  medical  language  we  express 
by  “coma”  and  “lethargy.”^  Gesenius  renders  tardemah  hy 
Latin  word  “ sopor,”  the  Hebrew  term  for  common  sleep  being 
shenah.  In  the  Vulgate  it  is  translated  “sopor”  {immisit  Deus 
soporem  in  Adam).  In  the  quotation  which  I have  given  from 
Calvin,  that  great  authority  renders  the  term  tardemah  by  the  ex- 
pression profound  “sopor”  {prof undo  sopore) ; and  Pool  quotes 
different  authorities  to  show  that  the  Hebrew  word  does  signify 
“ sopor”  of  a profound  kind,  “ notat  profundum  soporem''^ 

^ “ Notandum,  Adam  profundo  sopore  fuisse  demersum,  ut  nihil  doloris  sen- 
tiret.” — Johannis  Calvini  in  Lihruin  Geneseos  Coinmcntarius^  Hengstenherg’s 
edition,  p.  36. 

^ “ Ne  ablationis  costae  dolorem  sentiret.” — Toli  Synopsis  Criticorvsm  aliorum- 
que  Scripturce  Interpreturtiy  vol.  i.  p.  29.  See  also  the  same  opinion  expressed  in 
Rosenmuller’s  Scholia  Vetus  in  Testamentum,  vol.  i.  p.  106,  “ Adamo,  .somno  so- 
pito,  ne  dolorem  sentiret and  in  the  English  Commentaries  of  Bishop  Patrick, 
p.  14,  “Whereby  he  was  made  less  sensible  of  the  pain  which  otherwise  he  would 
have  felt  in  the  opening  his  side  and  of  Drs.  D’Oyly  and  Mant,  “Adam  was 
thus  less  sensible  of  bodily  pain  etc.  etc. 

^ “ In  Luther’s  German  Bible,  an  exactly  corresponding  expression,  ^Hiefen 
schlaf”  is  used.  In  Bathe’s  valued  Latin  version  of  the  Pentateuch,  a similar 
translation  is  given,  Dens  gravem  Adamo  soporem  immisit”  p.  27. 

^ “ Cataphora  (from  KaTacpepu,  to  sink  or  fall  down),  a term  used  by  some 
authors  to  designate  a state  of  coma,  and  by  others  an  unusually  profound  sleep.” 
— Hooper’s  Medical  Dictionary, 

® See  his  Synopsis  Criticorum  et  Scripturoe  Interpretum,  p.  29. 


60 


66 


DEFENCES  OF  ANAESTHESIA, 


CHAPTER  11. 

SAIVIE  SUBJECT  CONTINUED,  IN  A LETTER  TO  DR.  PROTHEROE 
SMITH,  OF  LONDON.^ 

Edmhiirgli,  July  1848. 

My  dear  Sir — According  to  promise,  I sit  clown  to  write  you  a 
few  hurried  notes  on  the  subject  of  the  avowed  religious  objections 
to  the  adoption  of  Ancesthesia  in  Human  Parturition. 

I regret  to  hear  from  you  that,  in  London,  the  progress  of 
Anaesthetic  Midwifery  is  impeded  by  any  groundless  allegations  as 
to  its  unscriptural  character ; and  I can  sincerely  sympathise  with 
you  in  your  exertions  to  annihilate  these  scruples.  Here,  in  Edin- 
burgh, I never  now  meet  with  any  objections  on  this  point,  for  the 
religious,  like  the  other  forms  of  opposition  to  chloroform,  have 
ceased  among  us. 

But  in  Edinburgh  matters  were  very  different  at  first.  I found 
many  patients  with  strong  religious  scruples  on  the  propriety  of  the 
practice.  Some  consulted  their  clergymen.  One  day,  on  meeting  the 

Rev.  Dr.  H , he  stopped  me  to  say  that  he  was  just  returning 

from  absolving  a patient’s  conscience  on  the  subject,  for  she  had 
taken  chloroform  during  labour,  and  so  avoided  suffering,  but  she 
had  felt  unhappy  ever  since,  under  the  idea  that  she  had  done 
something  very  wrong  and  very  sinful.  A few  among  the  clergy 
themselves,  for  a time,  joined  in  the  cry  against  the  new  practice.  I 
have  just  looked  up  a letter  which  a clergyman  VTote  to  a medical 
friend,  in  which  he  declares  that  chloroform  is  (I  quote  his  own 
words)  “ a decoy  of  Satan,  apparently  offering  itself  to  bless  woman  : 
but,  in  the  end,”  he  continues,  “ it  will  harden  society,  and  rob  God 
of  the  deep  earnest  cries  which  arise  in  time  of  trouble  for  help.” 
And  you  are  aware  how  earnestly  some  medical  men  attempted  to 
preach,  and,  as  you  state,  still  preach  against  it  on  religious  grounds. 
The  medical  friend  who  sent  me  the  note  from  which  I have  quoted, 
himself  read  a wild  and  fanatical  paper  before  the  Medical  Society 

^ See  Appendix  to  Dr.  Protkeroe  Smith’s  pamphlet  on  the  Scriptural  Authority 
for  the  Mitigation  of  the  Pains  of  Labour.  S.  Highley,  London,  1848. 


KELIGIOUS  OBJECTIONS  ANSWERED. 


57 


of on  the  subject ; and,  I am  told,  it  met  with  no  small  favour 

from  the  Society.  I have  enclosed  a copy  of  this  paper  for  your 
perusal.  Some  lecturers  on  midwifery,  in  London  and  Dublin,  pub- 
licly adopted  the  same  line  of  opposition  and  argument. 

With  the  view  of  meeting,  if  possible,  these  strange  and  ex- 
traordinary objections,  I wrote,  in  December  last,  a pamphlet  on  the 
subject  of  the  so-called  Religious  Reasons  against  the  employment  of 
Anoesthetic  Agents  in  Midwifery  and  Surgery.  After  its  publication, 
I received  a variety  of  written  and  verbal  communications  from  some 
of  the  best  theologians  and  most  esteemed  clergymen  here  and  else- 
where, and  of  all  churches — Presbyterian,  Independent,  Episco- 
palian, etc. — approving  of  the  views  which  I had  taken.  I have 
letters  of  the  same  kind  from  some  men  of  high  rank  in  your 
church ; and  a note  in  approval  was  brought  to  me,  emanating 
from  one  of  your  most  exalted  and  most  esteemed  episcopal 
dignitaries. 

The  pamphlet  itself,  however,  was  no  doubt  imperfect.  It  was 
principally  written  during  a day’s  confinement  to  my  room  when 
convalescing  from  the  prevailing  influenza.  I do  not  know  what 
views  you  intend  to  take  in  your  forthcoming  publication,  but  there 
are  some  points  on  which,  if  I had  had  time,  I would  perhaps  have 
more  insisted  on  in  mine ; and,  if  you  will  bear  with  me,  I will 
briefly  state  them. 

1.  In  the  whole  inquiry,  nothing  appeared  to  me  more  satis- 
factory or  striking  than  the  philosophic  precision  of  the  language  of 
the  Bible  upon  the  point ; and  I did  not  sufficiently  insist  upon  this, 
as  an  evidence  of  the  fact  that  the  primal  curse  on  woman  did  not 
refer  to  the  pure  physical  sufferings  and  agonies  of  parturition. 
Each  so-called  labour-pain  consists,  as  you  well  know,  of  two  distinct 
and  separate  elements ; viz.  first,  of  contraction  of  the  uterus  and 
other  assistant  muscles  ; and,  secondly,  of  sensations  of  pain,  more  or 
less  agonising,  accompanying  these  contractions,  and  directly  result- 
ing from  them.  Now,  I have  been  often  struck,  as  you  must  have 
been,  in  chloroform  labours,  with  the  fact  that,  in  the  anaesthetic 
state,  not  only  does  the  uterus  contract  powerfully,  but  the  abdominal 
muscles  often  do  so  also,  and  even  the  face  of  the  patient  will  some- 
times betoken  strong  expulsive  muscular  action,  while  all  accom- 
panying suffering  is  quite  annulled.  We  abrogate  the  second  element 
of  the  so-called  labour-pain,  without  destroying  the  first.  We  leave 
intact  the  expulsive  muscular  efforts,  but  remove  the  sense  and 
feeling  of  pain  accompanying  these  efforts.  It  is  only  of  late  that 


58 


DEFENCES  OF  ANAESTHESIA. 


these  two  elements  or  constituents  of  labour-pains  have  been  re- 
cognised and  studied  by  the  profession  as  two  separate  objects.  But 
it  is  surely,  as  I have  above  stated,  worthy  of  remark  and  wonder, 
that  the  language  of  the  Bible  is,  on  this  as  on  other  points,  strictly 
and  scientifically  correct,  and  long  ago  made,  wdth  perfect  precision, 
the  very  distinction  which  we  are  now-a-days  only  recognising.  For 
the  Hebrew  noun,  'etzehli,  distinctly  signifies  the  muscular  contraction 
or  effort,  and  the  nouns  liliil  and  hhabhel  as  distinctly  signify  the 
sensations  of  pain  accompanying  these  efforts ; and  you  are  aware, 
as  I have  elsewhere  fully  shown,  it  is  not  the  latter  but  the  former 
of  these  nouns  that  is  used  in  the  language  of  the  primary  curse  — 
“In  sorrow  (^etzehli)  shalt  thou  bring  forth.”  Now,  I repeat  the 
efforts  or  muscular  contractions  (the  'etzehh  of  the  curse)  are,  as  I 
have  just  stated,  left  in  their  full  and  complete  integrity  under  the 
state  of  anaesthesia ; while  the  pangs  or  sufferings  (or  lihil),  against 
which  the  language  of  the  curse  does  not  bear,  are  alone  annulled 
and  abrogated. 

2.  Some  of  youii*  London  medical  divines,  however,  argue,  I hear, 
that  'etzebh  must  mean  pain,  and  that,  as  meaning  such,  the  curse 
must  be  taken  literally ; and  hence  that  woman  must  be  allowed  to 
go  on  suffering.  In  the  pamphlet  referred  to,  I have  attempted  to 
answer  this  by  showing  that  then  we  of  the  sex  of  Adam  must 
adhere  literally,  also,  to  the  words  of  the  curse,  so  far  as  they  apply 
to  us,  and  hence  must  earn  our  bread  by  the  “ sweat  of  our  face,” 
and  by  that  only.  Nay,  the  very  physicians  who  thus  insist  on 
reading  and  acting  upon  this  and  other  texts  literally — and  literally 
only — forget,  I fear,  that,  according  to  their  own  doctrines,  in  prac- 
tising physic,  they  are  really  and  truly  practising  a profession  of  sin 
and  iniquity,  in  so  far  as  man  in  the  primeval  curse  was  doomed  to 
die,  and  yet  they  daily  and  hourly  persist  in  attempting  to  make  him 
live.  An  esteemed  clerical  friend,  in  wwiting  to  me  on  the  matter, 
stated  that  he  was  afraid  his  cloth  was  perhaps  even  more  sinful 
than  ours,  if  this  outrageous  vieAV  were  true;  for  the  introduction  of 
sin  was  the  consequence  of  the  fall,  and  the  church,  in  labouring  to 
banish  and  abrogate  that  effect — in  trying  to  turn  mankind  from 
sin — were  actually  trying  to  cancel  the  greatest  and  most  undoubted 
effects  of  the  first  curse  upon  the  human  race. 

3.  But  the  accoucheurs  and  surgeons  among  you  who  object  to 
the  use  of  chloroform,  on  the  ground  that  it  goes,  in  their  opinion, 
against  the  object  and  end  of  the  primeval  curse  upon  woman, 
strangely  forget  that  the  whole  science  and  whole  art  and  practice 


RELIGIOUS  OBJECTIONS  ANSWERED.  * 59 

of  midwifery  is,  in  its  essence  and  object,  one  continuous  effort  to 
mitigate  and  remove  the  effects  of  that  curse.  By  warm  baths, 
aperients,  regulated  diet,  etc.,  tliey  attempt  to  destroy  the  intensity 
of  the  approaching  pains  and  penalties  of  childbirth  ; — during  labour, 
they  use  counter-pressure  on  the  back,  to  relieve  the  intense  pains 
there  ; they  use  unguents,  perineal  support,  venesection,  etc.  etc., 
to  ease  the  pains  and  insure  the  safety  of  the  mother.  By  these 
means  they  succeeded  partially,  in  times  past,  in  mitigating  the 
sufferings  and  effects  of  parturition,  and  thought  they  committed  no 
sin.  But  a means  is  discovered  by  which  the  sufferings  of  the 
mother  may  be  relieved  far  more  effectually  ; and  then  they  im- 
mediately denounce  this  higher  amount  of  relief  as  a high  sin. 
Gaining  your  end,  according  to  their  religious  views,  imperfectly, 
was  no  sin — gaining  your  end  more  fully  and  perfectly  is,  they 
argue,  an  undiluted  and  unmitigated  piece  of  iniquity.  To  relieve 
our  patients,  however,  by  our  interference,  a little,  and  a little  only, 
is  assuredly,  in  a moral  and  religious  point  of  view,  just  as  sinful  as 
if  we  succeeded  in  affording  them  complete  relief  from  suffering. 
The  principle  of  interference  is  not  altered  by  the  degree  of  relief 
afforded  being  more  or  less,  greater  or  smaller.  “ For  whosoever 
shall  keep  the  whole  law,  and  yet  offend  in  one  point,  he  is  guilty 
of  all.”  If,  on  religious  grounds,  your  obstetric  friends  object  to 
relieving  entirely  a woman  of  her  worst  pains,  now  that  they  have 
the  means  of  doing  so,  they  must,  on  the  very  same  grounds,  refuse 
to  relieve  her  imperfectly  and  partially  of  these  or  any  other  pains 
and  sorrows  connected  with  parturition  ; they  must,  or  at  least 
ought  to  abstain,  in  fact,  from  all  obstetric  practices  whatsoever ; 
they  should,  in  short,  give  up  their  present  profession  as  a profession 
of  sin — and  “ in  the  sweat  of  their  face  ” eat  bread.  I can  see  no 
other  possible  alternative  for  them,  provided,  that  is  to  say,  they 
choose  to  reduce  actually  their  theory  into  practice.  If,  on  the 
other  hand,  they  think  it  not  sinful  to  relieve  their  female  patients, 
to  a small  amount,  from  the  alleged  sufferings  entailed  upon  them 
by  the  first  curse,  then  surely  it  is  not  sinful  in  them  to  relieve 
their  patients  from  their  sufferings  to  a far  greater  amount,  now  that 
they  have  the  power  of  doing  so — nay,  is  it  not  sinful  in  them 
obstinately  to  withhold  that  relief]  For,  “to  him  that  knoweth  to 
do  good,  and  doeth  it  not,  to  him  it  is  sin.'' 

These  remarks  apply  to  medical  practitioners.  And  if  any  of 
your  female  patients  hold  the  same  groundless  doctrine — a doctrine 
far  more  in  accordance  with  the  blindness  and  fatalism  of  Mahom- 


60 


DEFENCES  OF  ANAESTHESIA. 


medanism,  than  with  the  spirit  and  genius  of  Christianity — if  they 
hold  that  it  is  improper,  for  scriptural  reasons,  to  abrogate  the  pains 
and  sufferings  of  childbirth,  then  such  mothers  cannot  conscientiously 
content  themselves  with  rejecting  merely  the  use  of  chloroform  in 
annulling  the  pangs  of  parturition  ; they  must  reject  all  kinds  of 
medical  assistance  in  their  hour  of  travail ; they  must  give  up,  in- 
deed, all  assistance  whatever.  If  the  supposed  pains  and  perils  of 
the  primeval  curse  are  to  be  submitted  to,  on  the  ground  that  they 
are  divinely  appointed  and  unavoidable  ordeals — then  they  must  be 
submitted  to  in  all  their  unmitigated  power  and  plenitude  ; no 
doctor  must  sinfully  dare  to  stay  the  ebbing  stream  of  life,  if  a fatal 
flooding  suddenly  supervene  during  labour  ; no  nurse  must  venture, 
as  heretofore,  to  relieve  and  mitigate  the  agonies  of  the  shrieking 
mother  by  counter-pressure  to  her  back,  etc.,  “ for  whosoever  shall 
keep  the  .whole  law,  and  yet  offend  in  one  point,  he  (she)  is  guilty 
of  all.” 

4.  Those  who  object  to  the  adoption  of  anaesthesia  in  midwifery, 
on  religious  grounds,  entirely  forget  that,  if  God  had  really  willed 
the  pains  of  labour  to  be  irremovable,  no  possible  device  of  man 
could  ever  have  removed  them.  I have  elsewhere  attempted  to 
state  this  argument,  but  it  is  so  much  better  and  more  clearly  given 
in  a letter  in  my  possession,  from  the  pen  of  a clergyman.  Dr. 

, who  is  acknowledged  to  be  one  of  the  ripest  biblical 

scholars,  and  most  profound  theological  critics  and  writers  of  the 
present  day,  that  I will  cite  his  letter  at  length  to  you.  I received 
it  a few  days  after  the  publication  of  the  pamphlet  I have  referred 
to. 

“ I have  just  finished  the  perusal  of  your  pamphlet,  entitled 
Answer  to  the  Religious  Objections  advanced  against  the  Employment  of 
A ncesthetic  Agents  in  Midivifery  and  Surgery;  and  I cannot  refrain 
from  expressing  to  you,  though  almost  a stranger  to  you,  the  grati- 
fication which  I have  derived  from  it  I think  your  argument 
irrefragable,  both  as  respects  the  question  of  philology,  and  as 
respects  the  moral  question  ; and,  as  a theologian,  I feel  very  grateful 
to  you  for  so  ably  wiping  away  the  reproach  from  the  Bible,  of 
discouraging  any  attempt  to  mitigate  the  sufferings  of  mankind.  I 
am  very  sure  the  word  of  God,  the  revelation  of  his  love  and 
grace  to  man,  has  no  such  aspect ; and  that  it  is  only  injudicious 
and  ignorant  zeal  that  leads  any  of  its  professed  disciples  to  speak 
as  if  it  had. 

“ The  objection  which  you  so  ably  expose  is  not,  as  you  observe. 


RELIGIOUS  OBJECTIONS  ANSWERED. 


61 


novel — though  now,  for  the  first  time,  adduced  in  the  special  applica- 
tion of  it  to  the  relieving  of  the  pains  of  childbirth.  I remember 
when  many  pious  people  had  great  scruples  about  endeavouring  to 
emancipate  the  negroes,  on  the  ground  that  they  were  the  descend- 
ants of  Ham,  on  whom  the  curse  of  perpetual  slavery  had  been 
pronounced.  I should  not  be  surprised,  in  the  course  of  the  debates 
upon  the  emancipation  of  the  Jews,  to  find  some  members  pleading, 
as  some  have  pleaded  in  former  times,  that  to  give  a Jew  a legiti- 
mation in  any  commonwealth,  is  a plain  contravention  of  the  will 
and  word  of  God  concerning  that  people. 

“It  has  strongly  appeared  to  me,  for  many  years,  that  there  are 
two  principles  laid  down  in  Scripture,  a due  regard  to  which  would 
preserve  good  people  from  those  hasty  applications  of  Scripture  pre- 
dictions— whether  minatory  or  otherwise.  The  one  is  the  Apostle 
Peter’s  course  for  the  understanding  of  predictions,  that  no  prophecy 
is  self-interpreting  {idiag  s‘7:iXvffsug)”  from  which  it  follows,  that  in 
the  case  of  a prediction  threatening,  we  are  to  get  at  its  meaning 
' not  from  the  words  themselves  in  which  it  is  couched  as  from 
those  in  connection  with  the  events  or  circumstances  by  which 
the  Almighty  and  Allwise  fulfils  his  own  declarations.  The  other 
is  the  obvious  truth  that  God’s  blessing  and  God’s  curse  no  one  can 
reverse ; so  that  if  any  class  enjoying  God’s  blessing  meet  with 
pains,  or  any  class  exposed  to  his  curse  enjoy  relief  or  advantage, 
the  first  inference  is,  that  the  pain  was  not  excluded  by  the  blessing, 
nor  the  benefit  by  the  curse.  Applying  these  principles  to  the  case 
you  have  so  ably  discussed,  I came  speedily  to  the  conclusion  that, 
as  you  could  not  by  chloroform,  or  anything  else,  set  aside  God’s 
curse,  and  as  the  primary  threatening  is,  like  all  predictions,  to  be 
interpreted  by  events  in  God’s  providence,  the  mere  fact  that  by 
the  adhibition  of  that  agent  you  could  relieve  women  from  the 
agonies  of  childbirth,  was  to  me  proof  sufficient  that  these  mere 
agonies  were  not  designed  to  form  any  essential  part  of  that  curse. 
The  justice  of  this  conclusion  a priori  your  pamphlet  amply  substan- 
tiates by  inductive  reasoning.” 

5.  The  employment  of  anaesthesia  in  obstetric  and  medical 
practice  is  in  strict  consonance  with  the  whole  glorious  spirit  and 
beneficent  arrangements  of  the  Christian  dispensation — for  all  our 
greatest  divines  are  agreed,  I believe,  on  one  point,  viz.,  that  this 
dispensation,  in  the  application  of  its  principles  and  precepts,  is 
intended  and  calculated  not  only  to  regenerate  and  advance  our 
moral  condition,  but  more  and  more  to  ameliorate  the  physical 


f 


62  DEFENCES  OF  ANAESTHESIA. 

sufferings  and  state  of  mankind.  Witness,  for  example,  the  mighty 
power  and  resistless  influence  by  which  it  has  gradually  acted,  and 
is  acting,  through  the  development  of  its  rules  and  doctrines,  in  the 
extermination  from  this  earth  of  the  curse  of  human  slavery. 

6.  Some  thoughtlessly  argue  that  the  employment  of  anaesthetic 
means,  and  the  abrogation  of  pain  in  labour,  must  be  irreligious, 
because  it  is  “ unnatural.”  They  seem  to  think  that  it  looks  as  if 
we  fancied  that  nature,  or  rather  that  the  God  of  Nature,  had  made 
the  function  of  j^arturition  in  some  repects  imperfect  or  improper  in 
its  mechanism.  These  same  individuals  strangely  forget  that  they 
themselves  do  not  think  it  “unnatural”  to  assist  and  supplement 
other  physiological  functions  of  the  body.  They  wear  clothes  to 
assist  the  protecting  influence  of  the  skin,  and  do  not  think  that 
“ unnatural.”  They  use  cookery  and  condiments  to  aid  the  functions 
of  mastication  and  digestion.  Is  this  because  they  think  that 
nature  has  left  the  functions  of  mastication  and  digestion  imperfect 
in  their  formation  or  meclianism  1 They  constantly  ride  in  coaches, 
etc.  Is  the  function  of  progression  imperfect  in  man  ? “ How 

unnatural,”  exclaimed  an  Irish  lady  to  me  lately,  “ how  unnatural  it 
is  for  you  doctors  in  Edinburgh  to  take  away  the  j)ains  of  your 
patients  when  in  labour.”  “ How  unnatural,”  said  I,  “ is  it  for  you 
to  have  swam  over  from  Ireland  to  Scotland  against  wind  and  tide 
in  a steamboat.”  Many  habits  and  practices — in  fact,  almost  all 
the  habits  and  practices  of  civilised  life  are  really  and  fundamentally 
as  “ unnatural”  as  assisting  the  function  of  parturition  by  inducing 
ana3sthesia  during  it.  But  we  do  not  look  upon  them  as  such, 
simply  because  they  are  already  passed  into  acknowledged  and 
universal  adoption.  Those  who  lived  at  the  time  when  each 
separate  infringement  and  improvement  took  place,  could  perhaps 
tell  a story  of  doubt  and  opposition  not  unlike  that  which  we  can 
now  do  with  regard  to  anaesthetic  midwifery.  And  those  who  have 
taken  up  this  ground  of  opposition,  in  the  present  as  in  other  cases, 
always  seem,  for  the  time  being,  to  forget  that  it  is  God  who  has 
endowed  man  with  mental  powers  calculated  gradually  to  enable 
him  to  extend  his  knowledge  and  improve  his  earthly  condition,  and 
that  this  extension  and  this  improvement  are  so  far  evidently  allowed 
and  willed  by  God  himself. 

7.  An  additional  argument  is  suggested  in  a letter  lying  before 
me,  from  a gentleman  of  high  name  in  the  literary  world,  to  his  son, 
who  was  a pupil  of  mine  during  the  last  winter.  To  understand  its 
applicability,  however,  let  me  premise  one  or  two  words. 


RELIGIOUS  OBJECTIONS  ANSWERED. 


63 


I have  elsewhere  given  an  extensive  and  carefully  collected  series 
of  statistical  returns  from  various  British  hospitals,  showing  the 
operations  of  surgery  were  much  less  fatal  in  their  results  when 
patients  were  operated  on  under  the  condition  of  anaesthesia,  and 
consequently  without  any  attendant  suffering,  than  when,  formerly, 
they  were  submitted  to  all  the  horrors  and  agonies  of  the  surgeon’s 
knife  in  their  usual  waking  and  sensitive  state.^  Tims,  I found 
that,  while,  before  the  introduction  of  anaesthesia,  in  every  100  cases 
of  amputation  of  the  thigh  performed  in  our  hospitals,  from  40  to 
45  of  the  patients  died  ; the  same  amputation,  when  performed  upon 
anaesthetised  patients,  did  not  prove  fatal  to  more  than  25  in  the 
100  cases  ; or  in  other  words,  out  of  every  100  such  operations,  the 
previous  induction  of  anaesthesia  was  the  means  of  preserving  15  or 
20  human  lives.  So  much  are  all  our  surgeons  here  impressed  with 
the  fact  that  the  state  of  anaesthesia  saves  their  patients  alike  from 
pain,  and  from  the  subsequent  hazards  and  dangers  of  pain,  that  I 
believe  not  one  among  them  would  deem  himself  justified  in  sub- 
mitting a fellow-being  to  the  tortures  of  the  operating  table,  without 
the  previous  employment  of  chloroform.  And,  I believe,  you  are 
aware  that  we  also  use  it  here,  in  Edinburgh,  constantly  in  mid- 
wifery— its  omission  being  the  exception,  and  a rare  exception,  to 
the  general  rule  of  its  employment.  By  thus  shielding  our  patients 
against  the  more  severe  portion  of  the  pains  of  parturition,  we  not 
only  save  them  from  much  immediate  suffering,  but  we  save  their 
constitutions  also  from  the  effects  and  consequences  of  that  suffering  ; 
and,  as  a general  rule,  they  assuredly  make  both  more  rapid  and 
more  perfect  recoveries.  I most  sincerely  believe,  that  in  thus  can- 
celling the  pains  of  labour,  we  also,  to  a great  extent,  cancel  the 
perils  of  it ; for  all  our  highest  authorities  in  pathology  admit  that 
pain,  when  either  great  in  excess,  or  great  in  duration,  is  in  itself, 
and  by  itself,  deleterious  and  destructive  ; and  the  mortality  accom- 
panying parturition  is  regulated  principally  by  the  law  of  the  length 
and  degree  of  the  patient’s  struggles  and  sufferings.  In  the  Dublin 
Lying-in  Hospital,  when  under  Dr.  Collins’s  able  care,  out  of  all  the 
women,  7050  in  number,  who  were  delivered  within  two  hours  from 
the  commencement  of  labour,  22  died  ; or  one  in  every  320.  In  452 
of  his  cases,  the  labour  was  prolonged  above  twenty  hours,  and  out 
of  these  452  mothers,  42  died;  or  one  in  every  11  ; a difference 
enormous  in  amount,  and  one  strongly  calculated  to  force  us  all  to 


^ See  Part  ii.  chap.  6. 


64 


DEFENCES  OF  ANAESTHESIA. 


think  seriously  and  dispassionately  of  the  effects  of  severe  suffering 
upon  the  maternal  constitution. 

Now  the  writer  of  the  letter  to  which  I have  alluded  is  the 
author  of  one  of  the  most  eloquent  essays  in  the  English  language, 
on  the  holy  character  and  genuineness  of  the  Bible.  He  is  not  a 
physician,  though  deeply  read  in  medical,  as  in  all  other  forms  of 
knowledge;  and,  aware  of  the  dangers  and  destructive  properties  of 
severe  pain,  when  unmitigated  and  unrestrained,  he  reasons  thus : 
“ If  pain,  when  carried — as  in  parturition — to  the  stage  which  we 
call  agony,  or  intense  struggle  amongst  the  vital  functions,  brings 
with  it  some  danger  to  life,  as  I presume  no  one  can  deny  must  be 
the  case,  then  it  will  follow,  that,  knowingly  to  reject  a means  of 
mitigating,  or  wholly  cancelling,  the  attendant  suffering  and  its 
dangers  (now  that  such  a means  has  been  discovered),  travels,  in 
my  opinion,  on  the  road  towards  suicide.  If  I am  right  in  believing 
that  danger  to  life  lies  in  this  direction,  then,  clearly,  the  act  of  re- 
jecting the  remedy  against  it,  being  wilful,  lies  in  a suicidal  direction. 
It  is  even  worse  than  an  ordinary  movement  in  that  direction, 
because  it  affects  to  make  God  an  accomplice  through  the  Scriptures 
in  this  suicidal  movement,  nay,  the  primal  instigator  to  it,  by  means 
of  a supposed  curse  interdicting  the  use  of  any  means  whatever, 
though  revealed  by  Himself,  for  annulling  that  curse.”  The  same 
argument  which  is  here  brought  against  the  wilful  rejection  of 
anaesthetic  measures  by  the  patient,  necessarily  applies  with  the 
same  spirit,  but  with  some  changes  in  the  terms,  against  the  wilful 
rejection  of  the  same  means  by  the  medical  attendant. 

But  I must  be  done ; for  I fear  I have  exhausted  your  patience 
as  well  as  my  own  time.  Let  me  merely  add,  that  I am  sure  you 
deeply  regret  and  grieve  with  me  that  the  interests  of  genuine  re- 
ligion should  ever  and  anon  be  endangered  and  damaged  by  weak 
but  well-meaning  men  believing  and  urging  that  this  or  that  new 
improvement  in  medical  knowledge,  or  in  general  science,  is  against 
the  -words  or  spirit  of  Scripture.  We  may  always  rest  fully  and 
perfectly  assured  that  whatever  is  true  in  point  of  fact,  or  humane 
and  merciful  in  point  of  practice,  will  find  no  condemnation  in  the 
Word  of  God. 

With  many  apologies  for  the  unexpected  length  to  which  these 
remarks  have  extended, — Believe  me,  my  dear  Sir,  very  faithfully 
yours,  J-  Y.  Simpson. 


OPINIONS  AND  PKEJUDICES. 


65 


CHAPTER  III. 

MERE  OPINIONS  AND  PREJUDGMENTS  NOT  SUFFICIENT  TO  SETTLE  THE 
QUESTION  OF  THE  PROPRIETY  OR  IMPROPRIETY  OF  ANiESTHETIC 
AGENTS  : ILLUSTRATION  FROM  THE  HISTORY  OF  VACCINATION. 

“ The  multiplied  experiments  to  prevent  pain  in  surgical  operations,  which 
hear  so  delightful  a testimony  to  the  humanity  of  their  authors,  will  certainly,  in 
the  course  of  time,  he  crowned  with  success.” — Marx's  Akcsios — Letter  to  Herman 
Boerhaave. 

Edinburgh,  September  1847. 

During  the  latter  half  of  the  last  century,  30,000  individuals  were 
computed  to  die  annually  of  small-pox  in  England.*  From  the  official 
returns  of  the  Registrar-General,  it  appears  that  in  England  and 
Wales  the  number  that  perish  annually  of  this  same  disease  at  the 
present  time  is  reduced  to  less  than  10,000.*  In  England  alone, 
therefore,  the  absolute  mortality  from  small-pox  is  less  by  twenty 

^ Dr.  Gregory  observes,  “The  total  deaths  hy  small-pox  throughout  England 
were  estimated  at  about  45,000  annually.” — Cycloimdia  of  iSLedicine,  vol.  iv.  p. 
402.  Dr.  Haygarth  calculated  the  annual  number  of  deaths  from  small-pox  to 
amount  to  38,000  in  8,000,000  of  inhabitants. — See  the  data  of  his  computation  in 
his  Sketeh  of  a Plan  to  exterminate  Small-pox,  1793,  p.  144.  In  making  the 
various  computations  regarding  vaccination  in  the  text,  I have,  in  order  to  avoid 
the  possibility  of  error,  kept  all  the  calculations  considerably  below  the  ascer- 
tained data. 

2 During  the  five  years  from  1838  to  1842  inclusive,  there  died,  on  an  average, 
8893  individuals  yearly  of  small-pox.  In  1842,  only  2715  died. — See  Sixth 
Annual  Report  of  the  Registrar -General,  p.  514.  Formerly,  1 in  about  every  250 
of  the  general  population  died  annually  of  small-pox  ; now,  only  1 in  about  every 
1700.  In  England,  the  registration  of  every  birth  and  every  death  is  properly 
enforced  by  law.  If  the  registration  of  the  vaccination  of  each  child  were  enforced 
as  rigorously  as  the  registration  of  its  birth,  much  disease,  and  many  thousand 
human  lives  would  thus  undoubtedly  be  saved  annually  in  Great  Britain.  Surely 
it  is  a subject  well  worthy  of  the  attention  of  a benevolent  legislature.  AYe  see 
the  good  effects  of  such  interference  in  other  European  states.  For,  whilst  in 
England  (the  native  country  of  Jenner),  still  1 in  every  1700  inhabitants  dies 
annually  of  small-pox  ; in  Austria,  1 in  4800  dies  of  this  disease  ; in  France,  1 in 
11,000  ; and  in  Sweden,  on]y  1 in  27,000.  On  the  great  extent  of  the  number  of 
individuals  in  society  who  remain  unvaccinated,  see  some  excellent  remarks  by 
Dr.  Stark,  in  the  Edinburgh  Medieal  and  Surgical  Journal,  No.  161. 


6G 


DEFENCES  OF  ANyESTHESIA. 


thousand  a-year  than  it  was  half-a-century  ago.  If  a similar  rate 
of  reduction  in  the  number  of  deaths  from  small-pox  holds  good — 
as  we  have  every  reason  to  believe  is  the  case — in  the  other  king- 
doms of  Europe,  then,  out  of  the  220  millions  of  people  that  inhabit 
this  quarter  of  the  globe,  400,000  or  500,000  fewer  die  of  small-pox, 
than,  with  a similar  population,  would  have  died  from  this  malady 
fifty  years  ago.  In  other  words,  according  to  this  rate  of  computa- 
tion, there  are  now  preserved  from  death  by  small-pox  in  England, 
during  the  currency  of  a single  half-century,  a number  of  lives  greater 
in  amount  than  the  whole  existing  population  of  Wales.  There  are 
preserved  in  Europe,  during  the  same  period,  a number  of  lives 
greater  in  amount  than  the  whole  existing  population  of  Great 
Britain. 

For  this  mighty  triumph  of  medicine  over  one  of  the  most 
loathed  and  dreaded  forms  of  human  disease  and  death,  science 
stands  indebted  to  the  inestimable  discovery  of  Dr.  Jenner ; ^ and 
every  medical  man  is  ready  to  allow,  at  the  present  day,  that  his 
discovery  is  not  less  remarkable  in  consequence  of  its  gigantic  results 
and  amazing  success,  than  in  consequence  of  the  singular  simplicity 
and  safety  of  the  means  with  which  that  success  is  obtained.  For 
no  one  now  dreams  of  ever  expecting  any  deleterious  or  dangerous 
consequences  to  ensue  from  vaccination ; and,  indeed,  the  perform- 
ance of  it  has  been  mainly  or  entirely  conducted,  in  some  districts, 
by  non-professional  individuals — by  the  priest  as  well  as  bj^'  the 
physician — by  the  nurse  as  well  as  by  the  surgeon. 

Yet  at  the  time  of  Dr.  Jenner’s  first  public  announcement  of 
vaccination  in  1798,  and  for  many  years  subsequently,  the  proposal 
of  substituting  vaccine  for  variolous  inoculation  was  encountered  by 
various  members  of  the  profession,  with  incredulity  and  ridicule,  and 
direct  and  determined  opposition.  The  measure  by  which  he  taught 
medical  science  to  save  annually  from  death  thousands  of  human 

^ In  answer  to  those  who  have  affected  to  doubt  entirely  the  utility  of  physic 
and  physicians,  medical  science  may  proudly  point  to  the  results  of  vaccination. 
During  the  long  European  wars  connected  with  and  following  the  French  Eevolu- 
tion,  it  has  been  calculated  that  five  or  six  millions  of  human  lives  were  lost.  In 
Europe,  vaccination  has  already  preserved  from  death  a greater  number  of  human 
beings  than  were  sacrificed  during  the  course  of  these  wars.  The  lancet  of  Jenner 
has  saved  far  more  human  lives  than  the  sword  of  Napoleon  destroyed.  On 
these  devastating  European  wars  England  lavished  millions  of  money,  and  freely 
bestowed  honours,  peerages,  and  heavy  annual  pensions  upon  the  soldiers  who 
were  most  successful  in  fighting  her  battles  and  destroying  their  fellow-men  ; she 
grudgingly  rewarded  Jenner  with  thirty  thousand  pounds  for  saving  thirty 
thousand  of  her  subjects  annually. 


OPINIONS  AND  PREJUDICES. 


67 


lives  in  England,  and  hundreds  of  thousands  throughout  Europe, 
was,  on  its  first  introduction,  bitterly  denounced  and  decried  in 
different  quarters,  its  effects  doubted,  and  its  own  safety  and  pro- 
priety strongly  and  strenuously  called  in  question. 

Dr.  Squirrell  earnestly  and  publicly  supplicated  his  Majesty 
George  the  Third  to  suppress  “ the  destructive  practice  of  vaccine 
inoculation  throughout  his  dominions.”  ^ “ It  ought,”  observed 

Professor  Monro  of  Edinburgh,  “ to  be  prohibited  by  Act  of  Parlia- 
ment.” ^ “ The  College  of  Physicians  have,”  exclaimed  Dr.  Moseley, 

“ a duty  to  perform,  and  I trust  this  business  will  not  escape  them.”^ 
Others,  despairing  of  interference  on  the  part  of  the  King,  Parlia- 
ment, or  Colleges,  appealed  to  the  people  themselves.  “ It  would,” 
said  Dr.  Brown,  “ undoubtedly  be  downright  madness  to  imagine 
they  will  condescend  to  encourage  it.”  The  Anti-Vaccinarian 
Society  called  upon  the  public  “to  second  their  efforts  in  supporting 
the  cause  of  humanity  against  cow-pox  injuries,”  and  besought  their 
aid  to  suppress  “ the  cruel  despotic  tyranny  of  forcing  cow-pox 
misery  on  the  innocent  babes  of  the  poor — a gross  violation  of 
religion,  morality,  law,  and  humanity.”  ^ 

Frightful,  and  even  fatal  consequences  were  boldly  averred  to  be 
the  direct  and  immediate  results  of  vaccination.  Deaths  from  cow- 
pox  inoculation  were  published  in  the  mortality  bills  of  London. ° 
“ I have,”  alleged  Dr.  Moseley,  physician  to  the  Chelsea  Hospital, 
“ seen  children  die  of  the  cow-pox  without  losing  the  sense  of  tor- 
ment even  in  the  article  of  death.”  ^ Dr.  Kowley,  ph3^sician  to 
the  St.  Marylebone  Infirmary,  professed  to  publish  true  accounts 
of  fifty-nine  deaths  from  “cruel  vaccination;”’  and  added,  that 
“ when  humanity  reflects  ” on  these  and  (to  use  his  own  words)  “ a 
great  heap  of  victims  diseased  for  life,  and  likel}"  to  transmit  to 
posterity,  for  ages,  beastly  chronic  diseases,^  it  is  enough  to  freeze 
the  soul  with  horror.”  And  “it  is,”  he  exclaims,  “the  duty  of 
honourable  men  in  the  medical  profession  to  alarm  mankind  of  the 
impending  danger  of  vaccination  ; to  warn  society  of  the  multi- 
farious evils  that  await  them  in  the  form  of  this  mild  catholicon, 

^ Observations  on  the  pernicious  consequence  of  Cow-Pox  Inoculation.  2d  ed. 
London,  1606,  p.  vi.  ^ Edinburgh  Medical  and  Surgical  Journal,  vol.  xv.  p.  64. 

^ A Treatise  on  the  Lucs  Bovilla.  2d  edition.  London,  1805,  p.  xiv. 

^ A Letter  in  Reply  to  the  Surgeons  of  the  Vaccine  Institution.  Edinburgh, 
1809,  p.  96.  ® See  their  address  of  1806  in  Blair’s  Vaccine  Contest,  p.  56. 

® Mr  Blair’s  Pamphlet,  p,  95.  ^ Treatise,  p.  95. 

8 Co''<'-Pnclc  Inoculation  ; with  the  Modes  of  Treating  the  Beastlj’’  new  Diseases 
produced  by  Cow-Pock.  2d  edition,  1805,  p.  128. 


68 


DEFENCES  OF  ANAESTHESIA. 


of  a sweetened  potion  that  carries  fatal  poison  in  all  its  destruc- 
tive particles.”  i He  elsewhere  eloquently  declaims  against  “ affec- 
tionate parents  being  robbed  of  their  serenity,  and  the  minds  of 
tender  mothers  being  wrung  with  eternal  suspense,”  “ whilst  a few 
projectors  or  visionists  are  pursuing  their  deleterious  projects  on 
human  victims,”  and  perpetrating  a “ dangerous  innovation  which 
so  many  fatal  facts  illustrate.”  ^ 

Mr.  Lipscomb  urgently  maintained,  in  an  essay  on  small-pox 
inoculation,  published  in  1805,  that  cow-pox,  the  “new  scourge 
industriously  dispersed  to  afflict  the  children  of  men,”  is  “ sometimes 
fatal  of  itself,  and  that  the  diseases  introduced  or  brought  into  action 
by  it  may  be  also  sometimes  fatal,  and  can  never  be  completely 
guarded  against.”  ^ One  author  had  seen  “ numerous  instances  ” of 
vaccination  producing  eruptions,  remaining  “ for  months  and  even 
years  afterwards,  undermining  the  constitution,  and  very  frequently 
terminating  in  phagedenic  or  corroding  ulcers.”  And  he  had  like- 
wise witnessed  coughs,  dyspnoea,  hectic  marasmus,  tedious  and  diffi- 
cult to  eradicate,  etc.,  result  from  cow-pox.  “ Shocking  reflection,” 
he  adds,  “ to  a humane  mind,  that  a poison  should  thus  be  intro- 
duced into  the  human  constitution  without  the  plea  of  necessity,  or 
the  support  of  reason  and  experience.”  * “ Several  children,”  ob- 

serves Dr.  Moseley,  “ have  died  from  diseases  brought  on  by  the 
cow-pox  where  no  ulcerations  had  appeared,  and  others  have  lost 
their  nails  and  ends  of  their  fingers,  several  months  after  the  inocu- 
lation.”® “My  accounts  from  the  country  are,”  he  continues,  “full 
of  dismal  histories  of  ulcerated  arms  and  mortifications.”®  “ Blind- 
ness,” it  w^as  averred,  “ lameness,  and  deformity,  had  been  the  result 
of  employing  the  vaccine  in  innumerable  instances,  and  its  fatal 
venom  had  removed  many  an  infant  untimely  from  the  world.”  ^ 
Nay,  it  was  strenuously  maintained^  and  believed,  that  not  only 
were  various  old  maladies,  peculiar  to  man,  thus  excited  into  action 
by  the  “ cow-pox  poison,”  but  that  different  new  diseases  peculiar 
to  the  cow  were  sometimes  communicated  to  the  human  constitution 
by  vaccination.  “Various  beastly  diseases,”  writes  Dr.  Eowley, 

^ Cow-Pock  hioculatioii ; with  the  Modes  of  Treating  the  Beastly  new  Diseases 
produced  by  Cow-Pock.  2d  edition,  1805,  p.  14.  ” Ihicl.  p.  128. 

® Inoculation  for  the  Small-2')Ox  vindicated,  etc.,  1805,  p.  40. 

^ Observations  addressed  to  the  Public  on  the  Coio-pox,  pointing  out  the  dread- 
ful consequences  of  this  new  Disease,  so  recently  and  rashly  introduced  into  the 
Human  Constitution.  By  B.  Squirrel,  M.D.,  1805,  pp.  16,  17. 

® Treatise  on  the  Lues  Bovilla,  p.  118.  ® Ibid.  p.  92. 

7 Moore’s  History  of  Vaccination,  p.  39. 


OPINIONS  AND  PREJUDICES. 


69 


“ common  to  cattle,  have  appeared  among  the  human  species  since 
the  introduction  of  cow-pox — cow-pox  mange,  cow-pox  abscess,  cow- 
pox  ulcer,  cow-pox  gangrene,  cow-pox  mortification,  and  enormous 
hideous  swellings  of  the  face,  resembling  the  countenance  of  an  ox, 
with  the  eyes  distorted,  and  eyelids  forced  out  of  their  true  situation  ; 
diseased  joints,  etc.”^ 

This  was  published  in  1806,  eight  years  after  Dr.  Tenner’s  first 
essay  on  vaccination  appeared.  During  the  year  subsequent  to  the 
first  public  announcement  of  his  discovery.  Dr.  Moseley  suggested 
the  possibility  of  the  “ bestial  humour  ” of  cow-pox  producing  “ a 
brutal  fever,  exciting  incongruous  impressions  on  the  brain;”  and 
“ who  knows,”  says  he,  “ but  that  the  human  character  may  undergo 
strange  mutations  from  quadrupedan  sympathy,  and  that  some 
modern  Pasiphae  may  rival  the  fables  of  oldl”  Some,  after  vacci- 
nation, were  actually  supposed  to  “ cough  like  cows,”  and  “ bellow  like 
bulls.”  ^ And  one  anti-vaccinist  ingeniously  suggested  that  if  cow- 
pox  were  known  to  have  existed  in  a family,  this  fact  might  debar 
the  members  of  it  from  the  chances  of  matrimony.  For’  “ it  would,” 
he  remarks,  “ be  no  letter  of  recommendation,  and  it  would  be  cruel 
for  the  world  to  know  who  had  laboured  under  the  cow-pox  mange, 
evil,  ulcer,  or  any  other  beastly  disease ; it  might  infallibly  injure 
their  fortune  in  life,  particularly  in  matrimonial  alliances.  Who 
would  marry  into  any  family,  at  the  risk  of  their  offspring  having 
filthy  beastly  diseases  1 ” 

Nor  were  theological  reasons,  of  course,  wanting  for  calling  in 
question  the  orthodoxy  of  vaccination,  as  of  other  new  discoveries 
and  practices.”^  “Small-pox,”  argues  Dr.  Eowley,  “is  a visitation 

^ Cow-pox  Inoculation,  p.  105.  See  prefixed  to  the  work  the  coloured  portrait 
“of  a cow-poxed,  ox-faced  boy,”  with  two  scrofulous  abscesses,  which  were  atone 
time  alleged  to  indicate  sprouting  horns  ! — “This  boy,”  observed  Dr.  Rowley,  in 
a clinical  lecture  on  the  case,  “is  gradually  losing  the  human  lineaments,  and  his 
countenance  is  transmuting  into  the  visage  of  a cow.”  (Moore’s  History,  p.  46.) 
He  further  wrote — “A  great  number  of  new  complaints,  the  diseases  of  beasts, 
filthy  in  their  very  nature  and  appearance,  in  the  face,  eyes,  ears,  with  blindness 
and  deafness,  spreading  their  baneful  influence  over  the  whole  body,  have  been  not 
unfrequently  the  consequence  evidently  of  cow-pox  inoculation  ; either  originating 
from  the  grease  in  horses,  or  the  natural  diseases  of  cows,”  p.  12. 

2 Mr.  Ring,  in  his  treatise  on  cow-pox,  mentions  “ a lady  who  complained  that 
since  her  daughter  was  inoculated,  she  coughs  like  a cow,  and  has  grown  hairy  all 
over  her  body  ; and  Mr.  Blair  was  told,  on  a late  excursion  into  the  country,  that 
the  inoculation  of  the  cow-pox  was  discontinued  there,  because  those  who  had  been 
inoculated  in  that  manner  bellowed  like  hulls  !” — ^Blair’s  Vaccine  Contest,  xk  69. 

® Introduction  to  Rowley’s  pamphlet,  x^-  vii. 

^ As,  for  example,  small-pox  inoculation  : see  a “Sermon  against  the  danger- 


70 


DEFENCES  OF  ANAESTHESIA. 


from  God,  and  originates  in  man ; but  the  cow-pox  is  produced  by 
presumptuous,  impious  man.  The  former,  heaven  ordained ; the 
latter  is  perhaps  a daring  and  profane  violation  of  our  holy  religion.” 
And  he  subsequently  proposed,  “ whether  vaccination  be  agreeable 
to  the  will  and  ordinances  of  God,  as  a question  worthy  of  the  con- 
sideration of  the  contemplative  and  learned  ministers  of  the  Gospel 
of  Jesus  Christ ; and  whether  it  be  impious  and  profane,  thus  to 
wrest  out  of  the  hands  of  the  Almighty  the  divine  dispensation  of 
Providence!”^  “The  projects  of  these  vaccinators  seem,”  it  was 
affirmed,  “ to  bid  bold  defiance  to  heaven  itself,  even  to  the  will  of 
God.”^  “Providence,”  reasoned  another  author,  “never  intended 
that  the  vaccine  disease  should  affect  the  human  race,  else  why  had 
it  not,  before  this  time,  visited  the  inhabitants  of  the  globe.  The 
law  of  God,”  he  continues,  “ prohibits  the  practice  ; the  law  of  mian 
and  the  law  of  nature  loudly  exclaim  against  it.”^ 

In  short,  vaccination  was  opposed  and  denounced  on  a variety 
of  grounds.  It  was  alleged  to  be  occasionally  fatal  in  its  conse- 
quences; to  be  liable  to  excite  various  diseased  actions  and  pre- 
dispositions ; to  produce  diseases  new  to  the  human  constitution ; 
to  “be  impious,  unthinking,  profane,  and  irrational;”  to  be  an 
innovation,  neither  “established  on  the  basis  of  reason,  nor  sup- 
ported by  the  foundation  of  truth.”  ^ “ The  vaccine,”  exclaimed  one 

enemy  to  cow-pox  inoculation,  “ was  the  damnedest  thing  ever  pro- 
posed ; he  wished  the  inventors  were  all  hanged,  and  he  would  give 
his  vote  for  its  being  done.”^  And  strong  pictures  were  hung  up  to 
the  public  eye  of  the  miseries  it  would  infallibly  lead  to  in  case  of 


ous  and  sinful  practice  of  Inoculation,”  preached  at  St.  Andrew’s,  Holhom,  in  1722, 
by  Edmund  Massey,  M.A.  He  urges  various  theological  arguments  against  the 
“diabolical  operation  ” of  inoculation,  and  at  last  maintains  that,  even  if  it  were 
medically  successful,  it  was  not  to  be  courted,  for  he  believes,  if  mankind  should 
thus  “ happen  to  become  more  healthy,  it  is  a great  chance  but  they  would  be  less 
righteous.” — P.  26.  In  his  admirable  “Account  of  the  Inoculation  of  Small-Pox 
in  Scotland  (1765),”  Dr.  Monro  {primus)  states,  “the  first  and  most  general  pre- 
judice against  inoculation  is  its  being  deemed  a tempting  of  God’s  providence,  and 
therefore  a heinous  crime.” — P,  5.  “Clergymen,”  observes  Dr.  Baron,  in  hisX?/<5 
of  JciULcr,  vol.  i.  p.  231,  “ preached  from  their  pulpits  in  this  style  of  argument,  if 
so  it  might  be  calltyLl.  Some  Avent  so  far  as  to  pronounce  inoculation  an  invention 
of  Satan  himself,  and  its  abettors  Avere  charged  AA’ith  sorcery  and  atheism.  These 
things,”  he  adds,  “Avould  scarcely  obtain  ci*edence,  AA’ere  it  not  that  similar  argu- 
ments and  assertions  haA'C  been  employed  against  vaccination  itself.” 

^ PtOAvley’s  Pamphlet,  p.  9.  2 j/'accine  Contest,  p.  84. 

2 Preface  to  the  second  edition  of  Dr.  Squirrell’s  Observations,  p.  4. 

*■  Blair’s  Essay,  p.  83  ; and  Lipscomb’s  Pamphlet,  p.  28. 

® Moore’s  Reilly  to  the  Anti-Vaccinists,  1806,  p.  14. 


OPINIONS  AND  PREJUDICES. 


71 


the  recurrence  of  epidemic  small-pox.  “In  many  families,”^  writes 
an  author  whom  I have  already  quoted,  “ there  will  be  none  to  attend 
the  sick,  nurses  will  quit  their  jiatients  for  their  own  safety,  and 
servants  fly  from  their  masters’  houses  to  shun  the  pestilence.  Then 
we  shall  experience  an  horrid  scene  of  public  and  private  calamity — 
brought  on  by  a medical  experiment,  embraced  without  due  con- 
sideration, extended  by  a rash  transgression  over  the  bounds  of 
reason ; and,  after  the  fullest  conviction  of  its  inutility,  obstinately 
continued,  by  the  most  degrading  relapse  of  philosophy  that  ever 
disgraced  a civilised  world.” 

Such  were  the  chief  forms  of  opposition  and  argument  that  were 
stoutly  and  vigorously  urged  against  vaccination  during  the  earlier 
years  of  its  progress.  They  are  the  same  by  which  many  of  the 
happiest  and  greatest  improvements  in  our  profession  have  each  in 
turn  been  assailed  at  their  first  promulgation.  From  time  to  time 
in  the  march  of  medicine  and  other  allied  sciences,  some  earnest  and 
expanded  mind  conceives  and  elaborates  a great  and  novel  thought, 
destined  in  its  practical  application  to  ameliorate  the  condition  and 
promote  the  happiness  of  mankind.  But  hitherto,  almost  as  often 
as  the  human  intellect  has  been  thus  permitted  to  obtain  a new 
light,  or  strike  out  a new  discovery,  human  prejudices  and  passions 
have  instantly  sprung  up  to  deny  its  truth,  or  doubt  its  utility,  and 
thus  its  first  advances  are  never  welcomed  as  the  approach  of  a 
friend  to  humanity  and  science,  but  contested  and  battled  as  if  it 
were  the  attack  of  an  enemy.^  Practical  medicine,  in  its  past 
career,  is  full  of  instances  illustrative  of  this  remark.  Witness  the 
history  of  the  immense  and  now  almost  forgotten  difficulties  accom- 
panying the  first  introduction  of  mercury,  antimony,  and  cinchona- 

^ Preface  to  Treatise  on  Lues  Bovilla,  p,  23. 

2 This  remark  holds  true,  for  instance,  with  regard  to  small-pox  inoculation, 
etc.  etc.  Lord  Wharnclitfe,  in  his  edition  of  the  letters  and  works  of  Lady  Mary 
Wortley  Montagu,  after  giving  the  history  of  her  ladyship’s  introducing  the 
practice  of  small-pox  inoculation  into  England  from  the  East,  observes  : — “What 
an  arduous,  what  a fearful,  and,  we  may  add,  what  a thankless  enterprise  it  was, 
nobody  is  now  in  the  least  aware.  Those  who  have  heard  her  applauded  for  it 
ever  since  they  were  born,  may  naturally  conclude,  that  when  once  the  experi- 
ment had  been  made  and  had  proved  successful,  she  could  have  nothing  to  do  but 
to  sit  down  triumphant,  and  receive  the  thanks  and  blessings  of  her  countrymen. 
But  it  was  far  otherwise.  Lady  Mary  protested  that  in  the  four  or  five  years 
immediately  succeeding  her  arrival  at  home,  she  seldom,  passed  a day  without 
repenting  of  her  patriotic  undertaking ; and  she  vowed  that  she  never  would  have 
attempted  it  if  she  had  foreseen  the  vexation,  the  persecution,  and  even  the 
obloquy  it  brought  upon  her.  The  clamours  raised  against  the  practice,  and  of 
course  against  her,  were  beyond  belief.  The  faculty  all  rose  in  arms  to  a man, 
61 


72 


DEFENCES  OF  ANESTHESIA. 


bark,  into  medical  practice ; or  the  stern  obstinacy  with  which  the 
ligature  of  arteries  after  amputation  was  long,  long  rejected,  and 
cauteries  and  caustics  preferred  ; or  the  professional  and  religious 
prejudices  which  the  propriety  of  saving  human  life  by  inducing 
premature  labour  has  encountered  up  to  within  the  last  few  years. 
Further,  every  proposed  improvement  seems  to  be  met  with  the 
same  invariable  array  of  objections  and  arguments.  The  discovery 
may  be  new,  but  the  grounds  of  opposition  to  it  are  not  new — they 
are  merely  the  old  forms  of  doubt,  and  difficulty,  and  prejudice, 
used  on  former  occasions,  recalled  and  reproduced  anew.  Thus,  not 
only  in  their  leading  principles  and  spirit,  but  in  most  even  of  their 
minute  details,  identically  the  same  arguments  that  forty  or  fifty 
years  ago  were  urged  against  the  propriety  and  safety  of  vaccina- 
tion, or  a hundred  years  ago  against  small-pox  inoculation,*  have, 
within  the  last  few  months,  been  again  invoked  and  used  against 
the  employment  of  etherisation.  Time  has  amply  proved  how  futile 
and  inapplicable  these  arguments  were  as  directed  against  vaccina- 
tion. In  truth,  those  forms  of  reasoning  and  opposition  against  the 
employment  of  cow-pox  that,  some  forty  or  fifty  years  ago,  appeared 
to  many  members  of  the  profession  to  be  perfectly  conclusive  and 
insuperable,  now  read  and  appear  to  us  at  the  present  day  as  in  the 
highest  degree  illogical  and  absurd.  History  has  been  compared  to 
a mirror,  in  which  we  may  study  the  faults  of  our  predecessors, 
with  the  view  of  avoiding  the  same  errors  ourselves.  The  history 
of  cow-pox  is  certainly  calculated  to  teach  us  this  one  lesson,  that 
in  relation  to  the  truth  of  any  novel  doctrine  or  practice,  such  as 
vaccination  or  etherisation,  adverse  opinions  and  prejudgments  are, 
however  strongly  entertained,  or  however  strongly  expressed,  not  in 


foretelling  failure  and  the  most  disastrous  consequences ; the  clergj"  descanted  from 
their  pulpits  on  the  impiety  of  thus  seeking  to  take  events  out  of  the  hand  of 
Providence  ; the  common  people  were  taught  to  hoot  at  her  as  an  unnatural 
mother  who  had  risked  the  lives  of  her  own  children. 

“We  now  read  in  grave  medical  biography,  that  the  discovery  was  instantly 
hailed,  and  the  method  adopted,  by  the  principal  members  of  that  profession. 
Very  likely  they  left  this  recorded  ; for  whenever  an  invention  or  a project — and 
the  same  maybe  said  of  persons — has  made  its  way  so  well  by  itself  as  to  establish 
a certain  reputation,  most  people  are  sure  to  find  out  that  they  always  patronised 
it  from  the  beginning  ; and  a happy  gift  of  forgetfulness  enables  many  to  believe 
their  own  assertion.” — Letters  and  Works  of  Lady  Mary  Worthy  Montagu. 
Edited  by  her  givat-grandson  Lord  Wharncliffe,  vol.  i.  p.  55. 

^ “ The  very  same  objections,”  writes  Mr.  Moore  in  1805,  “accompanied  with 
the  same  species  of  proof,  were  adduced  against  it  (small-pox  inoculation),  as  are 
now  brouglit  against  vaccination.” — See  his  Lej^ty  to  the  Anti-Vaccinists,  p.  70. 


OPINIONS  AND  PKEJUDICES. 


73 


themselves  adequate,  as  some,  at  the  present  time,  would  seem  to 
believe,  to  decide  the  whole  matter  in  dispute,  either  in  one  direc- 
tion or  another.^  And  the  moral  is  obvious — that  while  minds 
anxious  to  promote  new  and  probable  inquiries  should  not  be 
intimidated  and  deterred  from  their  pursuit  by  such  prejudgments 
on  the  part  of  others,  those  who  are,  on  the  contrary,  anxious  to 
suppress  them,  should  not  venture  to  base  their  opposition  upon 
mere  impressions  and  mere  opinions  only.  The  ultimate  decision 
upon  such  investigations  ever  comes  to  be  founded,  not  upon  pre- 
conceived beliefs  or  hasty  deductions,  but  upon  the  careful  examina- 
tion and  evidence  of  a sufficient  body  of  accurate  and  well-ascertained 
facts.  During  the  last  six  months,  etherisation  has  been  used  to  a 
considerable  extent  in  British  surgery ; and,  at  the  present  time,  we 

^ I have  been  told  that  any  comparison  between  the  progress  of  vaccination 
and  etherisation  cannot  be  true  in  one  respect,  that  vaccination  was  at  once  and 
generally  received.  The  quotations  in  the  text  show  the  contrary  ; and  many  of 
the  strongest  adverse  opinions  which  I have  quoted  were  published  in  1805-6, 
seven  or  eight  years  after  Dr.  Jenner  published  his  first  admirable  essay  on  the 
subject  in  1798.  After  Dr.  Jenner  published  this  essay,  he  went  to  London,  and 
resided  there  for  nearly  three  months ; but  during  this  time,  “ with  all  his  efforts 
and  those  of  his  friends,  he  was  unable  in  the  metropolis  to  procure  one  person 
on  whom  he  could  exhibit  the  vaccine  disease.  Not  one  individual  would  submit 
to  it.  After  Jenner  left  I^ondon,  Mr.  Cline  made  the  first  experiment  in  London 
with  cow-pox,  by  inoculating  it  as  a counter-irritant  on  the  hip  of  a patient 
affected  with  morbus  coxarius.” — (Baron’s  Life  of  Jenner,  vol.  i.  p.  150.)  Jenner 
first  tried  artificial  vaccination  in  May  1876.  In  March  1800,  Mr.  (afterwards 
Sir  Matthew)  Tierney  wrote  him  from  Edinburgh,  where  he  was  then  a student, 
stating  that  “ Dr.  Gregory,  the  professor  of  physic,  knew  very  little  about  it,  and, 
of  course  did  not  encourage  it.  Mr.  Anderson,  a surgeon  at  Leith,  is  the  only 
person  here  who  has  tried  it.” — {Ib.  p.  376.)  As  late  as  1805,  the  popular  opinion 
in  London  was  much  shaken  with  regard  to  the  propriety  aud  safety  of  vaccina- 
tion. “The  influence,”  says  Mr.  Blair,  “of  false  rumours  and  distorted  facts 
operated  so  strongly  in  the  district  of  Bloomsbury  and  St.  Giles,  as  to  preclude 
even  a single  person  from  applying  for  vaccination  at  that  dispensary.” — (Pamphlet, 
p.  vi.)  Dr.  Moseley  boasts  (p.  13  of  his  Treatise,  second  edition),  that  at  that 
date,  1805,  the  middle  and  inferior  classes  in  London  had  “renounced  the 
delusion,”  and  W'ould  not  “ expose  their  children  to  cow-pox.”  Instances  of  more 
marked  popular  hostility  against  it  were  not  wanting  in  the  early  history  of  cow- 
pox.  Mr.  Gooch  states,  that  the  first  people  he  vaccinated  in  Hadleigh,  Suffolk, 
“were  absolutely  pelted  and  drove  into  their  houses  if  they  appeared  out.” — 

(Baron’s  Life,  vol.  i.  p.  382.)  In  the  town  of  St n,  Kincardineshire,  a surgeon 

was  lately  used  in  a similar  manner,  for  venturing  to  etherise  a patient  for  extrac- 
tion of  a tooth.  But  still  etherisation  has  made  more  progress  in  months  than  ' 
vaccination  affected  in  years  ; and  already,  within  a few  short  months,  a know- 
ledge of  it  has  spread  over  almost  the  civilised  world.  Within  these  few  days,  I 
received  a letter  of  consultation  from  a lady,  asking  some  directions  for  the  use  of 
etherisation  at  her  approaching  confinement,  in  October  next.  The  letter  was 
from  the  Far  West,  and  dated  “ ]\Iount  Morris,  Illinois,  United  States.” 


74 


DEFENCES  OF  ANAESTHESIA. 


are  perhaps  in  a condition  to  turn  and  look  back  upon  this  past 
experience  with  it,  in  order  to  endeavour  to  form,  from  the  existing 
facts  and  cases,  a proper  judgment  upon  its  merits  or  demerits,  and 
especially  in  order,  if  possible,  to  obtain  some  satisfactory  light 
upon  that  all-important  question  in  relation  to  its  employment — 
viz.  whether  its  adoption  increases  or  diminishes  the  usual  mortality 
consequent  upon  surgical  operations. 


PREVENTION  OF  PAIN  UNNECESSARY. 


75 


CHAPTER  IV. 

THE  PREVENTION  OF  PAIN  IN  SURGICAL  OPERATIONS 
ALLEGED  TO  BE  UNNECESSARY  AND  IMPROPER. 

Edinhurgli,  September  1847. 

There  is  one  strange  episode  which  has  been  frequently  reacted  in 
the  early  history  of  several  of  those  practical  improvements,  which 
we  all  now  proudly  refer  to,  and  rejoice  over,  as  among  the  greatest 
and  most  undoubted  advances  made  in  the  past  march  of  medical 
science.  It  is  this.  Some  striking  discovery  happens  to  be  made, 
or  some  great  improvement  suggested.  Its  worth  and  importance, 
betimes,  are  acknowledged  by  different  members  of  the  profession. 
Others,  however,  full  of  doubts  and  difficulties,  conjure  up  to  their 
own  minds,  and  to  the  minds  of  their  brethren,  all  the  usual  forms 
of  objection  to  the  new  view  that  has  been  propounded  ; and  the 
more  ardent  among  these  opponents  always  fix,  and  insist  "among 
other  points,  upon  this  special  and  singular  ground  of  objection, 
that  the  disease  or  evil  proposed  to  be  remedied  is  comparatively 
and  truly  less  obnoxious  in  its  character  than  was  in  general  pre- 
viously imagined,  that  its  removal  is,  consequently,  not  a matter  of 
much  moment,  and  that  the  new  and  artificial  measure  now  sug- 
gested for  that  purpose  is,  probably,  in  its  action  and  effects  on 
mankind,  really  more  dangerous  and  deleterious  than  the  very  state 
or  malady  which  it  was  proposed  to  remove  by  it. 

Take,  for  instance,  as  an  example  of  the  remark,  the  strong 
opposition  offered  first  to  variolous  inoculation,  and  afterwards  to 
vaccine  inoculation. 

It  has  been  repeatedly  calculated  in  regard  to  Europe,  that 
before  the  introduction  of  variolous  inoculation,  small-pox  regularly 
decimated  the  human  race,  one  out  of  every  ten  deaths  that 
occurred  being  a death  from  small-pox ; and  further,  the  disease 
was  reputed  fatal  to  at  least  one  out  of  every  six  or  eight  indi- 
viduals attacked  by  it.  Inoculation  was  introduced,  and  its  effects 
were  so  marked,  that  of  those  who  submitted  to  the  disease  in  this 


76 


DEFENCES  OF  ANiESTHESIA. 


form,  about  one  only  in  every  300  or  400  seems  to  have  perished.' 
Vaccination  was  discovered,  and  this  preventive  affection  was  found 
to  prove  rarely  or  never  yer  se  dangerous  or  fatal  to  life.  But  science, 
in  substituting — first,  inoculated  for  natural  small-pox ; and  secondly, 
cow-pox  for  inoculated  small-pox,  was  anxiously  combated  by  the 
double  argument,  that  the  old  evil  was  not  so  great  an  evil  as  it  was 
usually  represented  to  be,  and  that  perhaps  it  was  in  realit}^  safer 
and  better  than  the  new  measure  proposed  as  a substitute  for  it. 

Thus,  a hundred  and  twenty  years  ago,  among  the  various 
pamphlets  published  with  the  view  of  contesting  and  opposing  the 
propriety  of  the  newly  introduced  Variolous  Inoculation,  Mr.  How- 
grave,  whose  Essay  on  the  subject  is  one  of  the  best  of  the  period, 
maintains,  that  “the  small-pox  in  the  natural  way  very  rarely 
affects  life  where  the  habit  of  body  and  constitution  are  good;”"'' 
“ that  the  hazard  of  inoculation  is  not  only  not  considerably  less,  but 
considerably  greater  than  that  of  the  natural  small-pox ; ” ^ “ that 
this  “ new  and  strange  method,”  * “ more  frequently  produces  acci- 
dents than  the  natural  way,”  * that  it  is  “ not  only  unsafe  but 
uncertain,”  ® and  that,  “ all  persons  who  will  suffer  reason  to  de- 
termine their  opinion,  must  be  convinced  that  their  (the  inocula- 
tion) method  has  no  degree  of  safety  in  it,”^  Hence  we  can 
scarcely  wonder  when  he  “ affirms  that  the  best  method  is  to 
trust  Providence,  and  not  allow  mortal  man  to  inflict  diseases  upon 
us  at  his  pleasure.”  * Other  contemporary  writers  against  small- 
pox inoculation,  maintained,  upon  the  same  grounds,  the  same 
views  of  the  impropriety  of  the  practice.® 

Again,  forty  or  fifty  years  ago,  in  opposition  to  the  proposal  of 
Dr.  Jenner  to  introduce  vaccination,  or,  in  other  words,  to  substi- 

^ In  reference  to  the  mortality  of  natural  and  of  inoculated  small-pox,  Dr, 
Gregory,  Physician  to  the  Small-Pox  Hospital  of  London,  observes,  “ It  is  com- 
monly stated  that  one-fourth  of  those  who  are  attacked  by  small-pox  in  the 
natural  way  perish.” — Cydopcedia  of  Medicine,  vol.  iii.  p.  742.  And  “The 
average  number  of  deaths  (from  inoculated  small -pox)  at  the  Inoculation 
Hospital,  was  only  three  in  a thousand  (or  about  1 in  330),  In  the  wards  appro- 
priated to  the  casual  diseases  the  deatlis  were,  and  continue  to  be,  3 in  10,”  or 
more  than  1 in  4. — lUd.  vol.  iv.  p.  7 49. 

2 Reasons  against  the  Inoexdation  of  the  Snmll-pox.  London,  1724,  p.  67. 

3 lUd.  p.  72.  4 P.  8.  5 p,  6 p^  5^ 

7 Hid.  p.  28.  « Ihid.  p.  63. 

Sec,  for  instance,  the  Eev.  ]\Ir.  Delafaye’s  Sermon  on  Inoculation,  an  Inde- 
ensihle  Practice,  pp.  22,  23  ; or  A Letter  in  Reply,  by  H.  Bolaine,  Surgeon,  p. 
17.  Sparham’s  Reasons  against  the  Practice  of  Inoculating  the  Small-piox,  p.  27. 
Dr.  Wagstaffe’s  Letter  to  Dr.  Friend,  showing  the  danger  and  uncertainty  of 
Inoculating  the  Small-pox,  pp.  48,  49,  etc. 


PKEVENTION  OF  PAIN  UNNECESSAPvY. 


77 


tute  the  inoculation  of  cow-pox  for  the  inoculation  of  small-pox, 
the  same  objections  to  the  practice  were  reproduced.  Dr.  Moseley 
stated,'  for  example,  several  years  after  vaccination  was  introduced, 
that  “ the  mischiefs  of  the  natural  small-pox,  we  all  know,  are  great 
enough,  but  they  maybe  prevented  by  inoculation  that,  “instead 
of  1 in  300  dying  of  the  small-pox  from  inoculation,  there  need  not 
be  one  in  300,000  “ that  the  inoculated  cow-pox  is  not  a milder 

or  safer  disease  than  the  inoculated  small-pox ; ” and  that  “ the 
necessity  of  an  immediate  restoration  of  small-pox  inoculation  must 
strike  every  person  interested  in  the  welhire  of  society,  and  the 
happiness  of  his  fellow-creatures.  Cow-pox  (averred  Mr.  Drew 
and  Mr.  Forrester)  was  a “/ar  more  severe  disease  than  small-pox.”* 

“ Out  of  many  thousands,  nay  millions”  (so  wrote  Dr.  Itowley 
in  1805^),  “it  has  been  fully  proved  scarcely  any  one  died  from 
small-pox  inoculation;”  “it  was  safe,  mild,  and  certain;  therefore, 
cow-pox  inoculation  as  a substitute  was  absolutely  unnecessary  ;” 
besides,  the  substitute  itself  “ stands  condemned  by  the  experience 
of  veterans  in  the  profession;”  “disagreeable  events  (eruptions, 
abscesses,  gangrenes,  chronic  diseases,  etc.)  have  in  great  numbers 
followed,  and  can  be  traced  to  arise  from  cow-pox  inoculation,” 
while  small-pox  inoculation  was  free  from  them ; and  “ fifty-nine 
have  died,  and  a great  number  of  victims  become  diseased  for  life,” 
in  consequence  of  vaccination ; in  fact  “ the  senses,”  says  Dr. 
Rowley,  “ are  appalled,  and  the  pen  is  tired  of  recording  its  dread- 
ful disasters.” — (P.  61.)* 

But,  in  our  own  day,  exactly  the  same  line  of  argumentation 

^ Treatise  on  the  Lues  Bovilla,  2d  edit.  1805,  pp.  xv.  xx.  xxii.  110,  etc. 

2 See  Lipscomb’s  Essay,  p.  7,  and  Lij)Scomb’s  own  similar  opinion,  p.  39. 

® On  Cow -2)ox  Inoculation,  pp.  4,  31,  100,  128,  etc. 

^ See  the  works  also  of  other  anti-vaccinists  for  the  same  line  of  argument. 
Thus,  observes  Dr.  Squirrell,  the  small-pox  inoculation,  “ whatever  impediment 
it  might  have  met  with  at  its  introduction,  owing,  at  that  time,  to  a want  of  ex- 
perience in  the  practitioners,  is  now  a mild  and  harmless  disease,”  and  hence 
“ there  is  no  necessity  to. forsake  its  practice,”  for  that  of  vaccination,  with  “all 
its  difficulties,  ambiguities,  and  malignant  effects.”  “The  cow-pox  (he  argues 
more  at  length)  produces  malignant  effects,  vitiates  the  blood,  and  other  juices, 
and  is  tedious  as  well  as  difficult  to  cure  ; the  small-pox  inoculation  produces  no 
ill  consequences  whatever.  The  cow-pox  produces  very  ill  health  in  children  ; the 
small-pox  inoculation  improves  the  health  and  constitution,  and  carries  off  many 
complaints,  which  were  very  uncomfortable  both  to  the  parents  and  children. 
The  cow-pox  matter  is  taken  from  an  animal  diseased,  and  is  of  a specific  scrofu- 
lous kind,  as  is  proved  by  its  eflects  ; the  small-pox  matter  is  taken  from  a healthy 
subject,  and  produces  no  disease  whatever,  but  the  one  for  which  it  was  intended.” 
— Observations  on  the  Cow-yox,  pp.  24,  49,  55,  etc. 


78 


DEFENCES  OF  ANESTHESIA. 


that  was  thus  zealously  directed  against  the  adoption  of  artificial 
variolation  and  vaccination,  at  their  first  introduction  into  practice, 
is  now  as  zealously  directed  against  the  adoption  of  etherisation. 
For  precisely,  in  the  same  way  some  minds,  averse  to  the  employ- 
ment of  ether-inhalation,  anxiously  argue  that  there  is  not  only  no 
call  for  its  employment  in  surgery,  but  that  its  employment,  and 
the  result  which  it  produces — namely,  immunity  from  the  pliysical 
sufferings  inflicted  by  the  knife  of  the  surgeon — is  probably  a direct 
and  positive  evil. 

The  common  opinion  of  mankind  and  of  the  profession  in  regard 
to  the  pain  attendant  upon  surgical  operations,  seems,  till  of  late,  to 
have  been  unanimous  and  unchallenged.  The  human  agony  and 
torture  following  the  surgeon’s  knife  have  hitherto  been  borne  with 
and  submitted  to,  merely  because,  while  they  seemed  absolutely 
necessary  for  the  preservation  of  health  and  life,  they  were  con- 
sidered at  the  same  time  absolutely  unavoidable.  It  is  true  that 
differences  in  the  mental  and  physical  constitutions  of  different  men, 
enable  them  to  encounter  the  surgical  mangling  and  mutilation  of 
their  limbs  and  bodies,  with  different  degrees  of  equanimity  and 
hardihood.  And  under  special  morbid  states  of  the  nervous  system 
— in  the  way  both  of  great  excitement  and  great  overstraining  and 
collapse — flesh  and  bone  have  sometimes  been  extensively  cut  and 
divided  without  the  common  accompanying  feelings  and  common 
manifestations  of  acute  suffering.  But  the  every-day  experience  of 
mankind  in  every  age  shows  how  greatly  and  truly  the  reverse  of 
this  is  usually  the  fact.  And  all  past  human  testimony  on  this  point 
goes  fully  to  corroborate  the  truth  of  the  sentiment  which  England’s 
great  epic  poet  puts  into  the  mouth  of  the  wounded  Nisroch,  on  the 
first  occasion  in  which  wounds  were  ever  inflicted,  and  living  beings 
first  “ knew  pain  ” : — 

“ But  Pain  is  perfect  misery,  the  worst 
Of  evils,  and  excessive,  overturns 
All  patience. 

Nor  have  we  any  proper  test,  either  of  the  fortitude  with  which  it 
will  be  borne,  or  of  the  amount  of  pain  actually  endured  in  indi- 
vidual cases.  For  whilst  the  degree  of  outward  manifestation  of 
suffering,  shown  by  the  patient  on  the  rack  of  the  operating  table, 
affords  no  perfect  evidence  of  his  actual  feelings,  the  greatest  torture 
being  incapable  in  some  of  contorting  a muscle,  or  eliciting  a groan, 
and  the  slightest  scratch  forcing  screams  and  cries  from  others ; 
neither,  on  the  other  hand,  is  the  degree  of  equanimity  and  endur- 


PREVENTION  OF  PAIN  UNNECESSARY. 


79 


ance  with  which  the  agony  of  a surgical  operation  is  submitted  to, 
any  true  and  direct  criterion  of  the  natural  moral  strength  and 
mental  courage  of  the  patient.  Sometimes  the  sailor  and  soldier, 
who  would  not  feel  one  moment’s  dread  in  facing,  under  the  most 
desperate  circumstances,  the  sword  and  fire  of  the  enemy,  will  quail 
before  the  very  thought  of  having  his  living  flesh  deliberately  cut 
and  mutilated  by  the  cold  steel  of  the  surgeon.^  And  thus,  the 
mere  fear  and  horror  of  encountering  the  pain  and  agony  of  a 
surgical  operation,  will  sometimes,  by  unnerving  the  strongest  mind 
and  boldest  heart,  bring  on,  as  a consequence,  such  a depressed  state 
of  the  system,  as  certainly  by  no  means  places  the  patient  in  a state 
favourable  for  securing  a happy  and  successful  result.  “ An  ex- 
traordinary excitement  of  mind,”  observes  Mr.  Travers,  “ such  as  is 
produced  by  dread,  or  by  the  screwing  up  of  the  system  for  the 
endurance  of  painful  operations,  when  it  is  already  much  depressed 
and  enervated  by  continued  suffering,  or  apprehension  of  it,  some- 
times proves  suddenly  fatal.”  * 

In  the  greater  operations  of  surgery,  the  employment  of  ether- 
isation is  not  only,  thus  far,  a great  blessing  to  the  patient,  but  it  is 
a great  boon  also  to  the  practitioner.  It  is  a benefit  to  the  operator, 
as  well  as  to  those  operated  upon.  For,  whilst  it  relieves  the  one 
from  all  the  feelings  of  agonising  pain,  it  relieves  the  other  from  the 
feelings  of  inflicting  such  pain  upon  a fellow-creature.  Humanity, 

^ Tlie  following  illustrative  anecdote  refers  to  Lord  D , assuredly  one  of  the 

bravest  admirals  in  the  English  service,  and  a man  of  all  others  Avhom  his 
country  has  long  looked  upon  as  the  very  personification  of  valour  and  courage. 

The  injury  alluded  to  was  received  in  cutting  off  the  Spanish  frigate  A , one 

of  the  most  daring  feats  attempted  in  modern  Avarfare.  I extract  the  account 
from  an  article  on  Etherisation  in  the  North  British  Btvieiv,  excellent  in  matter, 
in  manner,  and  in  feeling,  and  Avritten  by  one  or  the  most  distinguished  surgical 
practitioners  and  authors  of  the  present  day.  “ AVe  remember,”  says  the  revieAver, 
“the  case  of  a gallant  admiral— one  of  the  bravest  hearts  that  eA'er  beat,  in  a 
service  Avhere  men  of  every  grade  are,  to  a proverb,  dauntless — Avho,  in  the  opening 
of  his  distinguished  career,  had  been  engaged  in  cutting  out  an  enemy’s  frigate. 
From  the  gun-boat  he  climbed  up  the  ship’s  steep  side,  and,  foremost  of  his  creAA', 
had  reached  the  buhvarks,  Avdien  receiving  a stunning  bloAV,  he  fell  backAA^ards  into 
his  boat  again,  striking  his  back  violently  on  the  tholpin.  Many  years  afteriA^ards 
a tumour  had  groAvn  on  the  injured  part,  and  at  length  the  admiral — gi’ey,  and 
bent  in  years,  found  it  advisable  that  this  groAAdh  should  be  removed.  The  man 
that  never  feared  death  in  its  most  appalling  form,  Avhile  in  the  discharge  of  duty, 
now  shrank  from  the  surgeon’s  knife  ; the  removal,  contemplated  Avith  a feeling 
almost  akin  to  fear,  Avas  long  deferred  ; and  at  length,  half  stupified  by  opium 
though  he  Avas,  a most  unsteady  patient  did  he  prove  during  the  operation.” — 
North  British  Bevieiv  for  May  1847,  !>.  1G9. 

^ Travers  on  Constitutional  Irritation,  vol.  i.  p.  22. 


80 


DEFENCES  OF  ANESTHESIA. 


in  the  fullest  sense  of  the  term,  is  the  great  object  of  the  healing 
art,  and  the  aim  alike  of  the  surgeon  as  of  the  physician.  Hitherto 
the  professional  duty  of  the  surgeon  has  compelled  him  to  inflict 
present  suffering  upon  his  patients,  with  a prospective  view  to  their 
own  ultimate  benefit  and  advantage.  And  surely  there  is  no  one, 
however  much  inured  to  the  sight  and  shriek  of  pain,  who  would 
not  rejoice  to  be  able  to  obtain  these  advantages  for  his  patients, 
without  compelling  them  to  pass  through  so  severe  an  ordeal  as  the 
tortures  of  the  operating  table.  If,  as  some  few  operators  them- 
selves have  indiscreetly  boasted,  their  hearts  have  become  so  hardened 
by  education  and  custom  as  not  to  be  affected  by  the  sufferings  of 
those  submitted  to  their  knives,  it  is  still  pleasing  and  refreshing  to 
•know  that  this  change  in  the  human  feelings,  and  this  artificial 
violation  of  one  of  the  first  laws  in  human  nature — namely,  sym- 
pathy with  the  sufferings  of  others — is  by  no  means  necessary  to 
make  a man  a perfect  surgeon. 

Perhaps  no  surgeon  ever  operated,  either  more  frequently  or 
more  successfully,  than  the  celebrated  Cheselden.  In  St.  Thomas’s 
Hospital  alone,  and  exclusively  of  his  practice  elsewhere,  he  per- 
formed lithotomy  upwards  of  two  hundred  times,  and  with  results 
that  have  never  yet  been  surpassed  by  any  other  operator.  But  he 
adds,  in  language  bearing  all  the  simple  impressiveness  of  truth,  “ If 
I have  any  reputation  in  this  way,  I have  earned  it  dearly ; for  no 
one  ever  endured  more  anxiety  and  sickness  before  an  operation ; 
yet,  from  the  time  I began  to  operate,  all  uneasiness  ceased ; and,  if 
I have  had  better  success  than  some  others,  I do  not  impute  it  to 
more  knowledge,  but  to  the  happiness  of  a mind  that  was  never 
ruffled  or  disconcerted,  and  a hand  that  never  trembled  during  any 
operation.”^  It  was  under  this  great  master  that  John  Hunter 
received  his  first  lessons  in  surgery ; and  the  biographer  of  Hunter 
tells  us  that,  to  quote  his  words,  “ Cheselden’s  manners  were  ex- 
ceedingly kind  and  gentle,  and,  notwithstanding  the  extensive  prac- 
tice he  had  enjoyed,  he  always,  before  an  operation,  felt  sick  at  the 
thoughts  of  the  jjain  he  was  about  to  inflict ; though,  during  its  per- 
formance, his  coolness  and  presence  of  mind  never  forsook  him. 
Such  feelings,”  adds  Mr.  Ottley,  “ are  in  a less  marked  degree,  per- 
haps, far  more  commonly  experienced  than  is  generally  supposed,  by 
the  very  best  surgeons,  previously  to  undertaking  operations  of 
importance.”  ^ And,  no  doubt,  it  is  the  desire  to  diminish  the 

^ Clieselden’s  Anatomy  of  the  Human  Body,  5th  edition,  p.  333. 

- Ottley’ s Life  of  John  Hunter,  in  Mr.  Palmer’s  edition  of  his  works,  vol. 
i.  p.  9. 


PREVENTION  OF  PAIN  UNNECESSARY. 


81 


actual  amount  of  pain  endured  by  patients,  by  curtailing  the  actual 
duration  of  it,  that  has  led  many  of  our  best  surgeons,  with  praise- 
worthy earnestness,  to  attempt  to  invent  new  and  more  rapid  modes 
for  performing  particular  operations, — a field  in  which  no  small 
degree  of  success  has  consequently  been  met  with. 

A new  era,  however,  arrives  in  chirurgical  science,  and  a measure 
is,  at  last,  brought  to  light,  through  the  influence  of  which  surgeons 
may  perform  operations,  and  patients  submit  to  them,  even  when  of 
a prolonged  nature,  without  the  necessity  of  pain.  It  is  found  that 
the  excruciating  tortures  and  writhings,  and  shrieks  of  patients  on 
the  operating  table,  may  be  saved ; and  yet  the  required  operations 
be  as  well  and  perfectly  executed  as  before.  Scarcely,  however,  is 
this  glad  and  glorious  discovery  announced  and  acted  upon,  than 
another  new,  and,  if  possible,  still  stranger  discovery,  is  broached 
and  anxiously  promulgated  ; namely,  that  in  cutting  the  living  flesh 
of  man,  the  surgeon’s  knife  does  not,  after  all,  produce  any  very 
remarkable  or  very  important  amount  of  pain,  and  that  immunity 
from  this  pain  during  operations  would  be,  perhaps,  an  evil  rather 
than  a good  to  humanity — a calamity  rather  than  a blessing. 

At  a meeting  of  the  South  London  Medical  Society,  held  in 
April  last,  Dr.  Gull  read  a paper  on  the  injurious  effects  of  etlier- 
inhalation,  and  ended  his  communication  with  queries  as  to  the 
“ desirability  of  removing  pain,”  etc.'  Mr.  Bransby  Cooper,  surgeon 
to  Guy’s  Hospital,  afterwards  affirmed  it  as  his  opinion,  “ that  pain 
was  a premonitory  condition,  no  doubt  fitting  parts,  the  subject  of 
lesion,  to  reparatory  action,  and,  therefore,  he  (Mr.  Cooper)  should 
feel  averse  to  the  prevention  of  it.”  ‘ “ Pain,”  argues  Mr.  Nunn, 

surgeon  to  the  Colchester  and  Essex  Hospital,  in  some  observations 
against  ether-inhalation, — “ pain  (toothache  ?)  is,  doubtless,  our  great 
safeguard  under  ordinary  circumstances ; but  for  it  we  should  be 
hourly  falling  into  danger ; and  I am,”  he  continues,  “ inclined  to 
believe  that  pain  should  be  considered  as  a healthy  indication,  and  as 
an  essential  concomitant  wdth  surgical  operations,  and  that  it  is  amply 
compensated  by  the  effects  it  produces  on  the  system,  as  the  natural 
incentive  to  reparative  action.”  “ Arguing  in  a similar  but  still 
more  bitter  strain  against  etherisation.  Dr.  Pickford  affirms  that 
“pain  during  operations  is,  in  the  majority  of  cases,  even  desirable; 
and  its  prevention  or  annihilation  is,  for  the  most  part,  hazardous 

^ See  Report  of  the  Meeting  in  the  London  Medical  Gazette  for  April  30,  1847, 

p.  777.  2 

3 London  Medkal  Gazette  for  March  5,  p.  415. 


82 


DEFENCES  OF  ANESTHESIA. 


to  the  patient.”  ^ Upon  one  of  the  first  communications  being  given 
in  to  the  French  Academy  of  Sciences  upon  etherisation,  M.  Ma- 
gendie,  the  distinguished  physiologist,  maintained  ^ that  “ pain  has 
always  its  usefulness  j”  he  doubted  if  there  was  a true  advantage 
“ in  suppressing  pain,  by  rendering  patients  insensible,  during  an 
operation  and  argued  that  “ it  was  a trivial  matter  to  suffer 
{cest  peu  de  chose  de  souffrir),  and  a discovery  whose  object  was  to 
prevent  pain  was*  of  a slight  {mediocre)  interest  only.” 

It  would  be  as  idle  as  it  would  be  useless  to  confute  by  mere 
argument  the  preceding  allegations,  in  regard  to  the  supposed  neces- 
sity and  advantages  of  pain  in  surgical  operations.  For,  in  fact,  the 
whole  question  amounts  to  this : — Mankind  are  perfectly  agreed, 
that  the  cutting  and  mutilation  of  the  living  human  body  is  painful, 
however  loudly  surgeons  may  preach  to  the  contrary  ; and  medical 
men  have  hitherto  assented,  without  one  contradictory  voice,  to  the 
self-evident  aphorism  of  Galen,  that  pain  is  useless  to  the  pained 
{dolor  dolentihus  inutilis  est).  If  we  find  then,  as  we  do  now,  a few 
men  entertaining  and  expressing  opinions  on  these  points  so  very 
different  from  the  general  ideas  and  general  experience  of  mankind, 
these  opinions  can  scarcely  be  looked  upon  as  aught  else  than  indi- 
cations of  a strange  degree  of  eccentricity  of  thought  upon  one 
special  subject.  And  if  the  same  line  of  thought  that  they  apply 
to  pain  were  extended,  as  it  should  be  if  true  in  principle,  to  other 
diseases  or  effects  of  disease,  the  untenable  and  irrational  character 
of  it  would  lead  to  conclusions  that  might,  ^perhaps,  surprise  and 
startle  even  those  minds  that  at  present  employ  it  against  etheri- 
sation. For  if  physical  pain  and  agony  be  a blessing  and  benefit, 
and  not  an  evil  and  a calamity  to  be  eschewed,  then  all  other  morbid 
symptoms  and  affections  should  equally,  upon  the  very  same  grounds, 
be  included  under  the  same  category — their  pres'ence  endured  and 
courted,  and  their  removal  forbidden  and  avoided  ; diseases  and 
death  are  parts  of  the  great  economy  and  general  police  of  nature, 
and  the  labours  of  the  physician  and  surgeon  to  counteract  their 
agency,  should  be  denounced  and  decried  as  unnecessary  and 
improper. 

Let  us  view  the  subject,  however,  calmly,  and  as  a question  in 
pathology.  And  that  pain  is,  per  se,  and  especially  when  in  excess, 
a condition  which  is  not  only  trying  and  difficult  for  any  exertion 

^ On  the  Injurious  Effects  of  the  Inhalation  of  Ether,  in  the  Edinburgh  Medical 
and  Surgical  Journal  for  July  1847,  p.  258. 

" Gazette  Medicale  dc  Paris,  6th  Feh.  1847,  pp.  112,  113. 


PREVENTION  OF  PAIN  UNNECESSARY. 


83 


of  human  fortitude  to  bear,  but  at  the  same  time  directly  injurious 
and  damaging  in  its  action  upon  the  constitution,  and  sometimes 
very  fatal  in  its  effects,  is  a practical  truth  that  many  of  our  best 
surgeons  and  soundest  pathologists  have  long  amjdy  acknowledged 
and  attested,  and  that,  too,  without  any  prejudgment  in  regard  to 
it,  or,  at  all  events,  without  any  view  to  such  an  extraordinary 
proposition  as  the  now  alleged  impolicy  and  impropriety  of  abolish- 
ing it.  Speaking  of  the  pains  of  wounds,  the  great  father  of  French 
surgery,  Ambrose  Pare,  pithily  tells  us,  that  it  “ ought  to  be 
assuaged ; because,”  adds  he,  “ nothing  so  much  dejects  the  powers 
of  the  patient  (prosterne  et  ahatte  les  vertus  dii  mdlade)^  ^ “ Mere 

pain,”  observed  the  late  distinguished  Dr.  Gooch,  “ can  destroy  life.”  ^ 
“Pain,”  according  to  Mr.  Travers,  “when  amounting  to  a certain 
degree  of  intensity  and  duration,  is  of  itself  destructive.”  ’ “ Pain 

in  excess,”  he  again  remarks,  “ exhausts  the  principle  of  life  ; so  that 
either  its  continuance  without  intermission,  or  the  superaddition  of 
the  slightest  shock  subsequent  to  its  endurance  for  a certain  period, 
is  fatal.  In  operations  protracted  by  unforeseen  difficulties,  as  in 
cases  of  lithotomy,  in  which  the  stone  is  of  such  magnitude  as  to  re- 
quire crushing,  the  patient  has  begun  to  die  upon  the  table.  The 
same  happens  in  parturition,  etc.,  protracted  by  mechanical  im- 
pediment, etc.”^  Again,  “ Bodily  exhaustion  from  continued  pain, 
spasm,  and  other  causes,  not  unfrequently  proves  suddenly  fatal.  I 
have  often  observed  a sudden  deliquium  at  the  conclusion  of  air 
operation  for  recent  injury,  arising  evidently  from  the  exhaustion  of 
the  nervous  system  in  the  effort  to  support  it.”^  “ Great  sensibility 

or  excessive  pain  attendant  on  an  injury  (or  operation)  has,”  remarks 

1 Pares  TVorhs,  Johnston’s  Translation,  p.  329. 

2 Synopsis  of  Midwifery,  1826,  p.  239. 

® An  inquiry  concerning  that  disturbed  state  of  the  Vital  Functions,  usually 
denominated  Constitutional  Irritation^  1826,  p.  65. 

^ Travers  on  Constitutional  Lritation,  vol.  i.  76.  The  statistical  data  pub- 
lished by  Dr.  Collins  in  his  excellent  Report  of  the  Dublin  Lying-in  Hospital, 
proves  how  true  Mr.  Travers’s  remark  holds  as  a general  principle  with  regard  to 
the  effect  of  pain  in  protracted  parturition.  In  fact,  the  maternal  mortality 
attendant  upon  parturition  regularly  increases  in  a ratio  progressive  with  the 
increased  duration  of  the  woman’s  sufferings.  Thus,  according  to  calculations 
which  I have  made  from  Dr.  Collins’s  data,  while  in  the  women  whose  sufferings 
were  terminated  within  two  hours,  only  one  in  about  320  of  the  mothers  died  ; 
where  the  labour  varied  in  duration  from  two  to  six  hours,  one  in.  145  died  ; in 
those  in  whom  it  continued  from  seven  to  twelve  hours,  one  in  80  died ; when 
it  endured  from  twelve  to  thirty-six  hours,  one  in  23  died  ; and  out  of  those  whose 
sufferings  were  prolonged  beyond  thirty-six  hours,  one  in  every  6 perished. 

® Travers,  p.  24. 


84 


DEFENCES  OF  ANESTHESIA. 


Professor  Burns,  “ two  effects.  First,  it  exhausts  both  the  system 
and  the  part : and,  secondly,  it  acts  as  an  exciting  cause  of  inflam- 
mation, a disease  apt  enough  to  take  place  from  the  injury  itself.”^ 
“We  have  many  facts,”  observes  Professor  Alison,.,  “to  prove  that 
various  violent  and  overpowering  sensations,  intense  pain,  etc.,  when 
acting  in  the  utmost  intensity,  affect  the  circulating  system  just  as  a 
concussion  does,  and  sometimes  with  fatal  effect — especially  when 
they  take  place  in  a state  of  unusual  weakness  or  exhaustion.”  Dr. 
Banking  has  lately  published  a striking  instance  of  the  fatally  de- 
pressing effects  of  extreme  pain.  It  occurred  in  a case  in  which  a 
ligature  was  applied  for  the  cure  of  an  erectile  tumour  of  the  breast. 
“ The  patient,”  he  relates,  “ a healthy  female,  bore  the  initiatory 
steps  of  the  operation  without  a murmur,  without  failure  of  pulse, 
and  without  change  of  countenance.  The  instant  the  ligature  was 
tightened,  which  it  was  with  the  full  force  of  two  surgeons,  she  gave 
a yell  of  agony,  the  pulse  became  imperceptible,  the  countenance 
became  ghastly  pale,  and  in  eighteen  hours  she  was  a corpse.”^ 

But  it  is,  I believe,  needless  to  accumulate  surperfluous  proof  on 
a point  on  which  the  observations  and  feelings  of  the  profession  and 
of  mankind  are  sufficiently  agreed — namely,  that  bodily  pain,  parti- 
cularly such  excess  of  pain  as,  with  all  its  concomitant  fears  and 
sickening  horrors,  accompanies  the  larger  operations  in  surgery,  is, 
with  very  few,  if  indeed  any  exceptions,  morally  and  physically  a 
mighty  and  unqualified  evil.  And,  surely,  any  means  by  which  its 
abolition  could  possibly  be  accomplished,  with  perfect  security  and 
safety,  deserves  to  be  joyfully  and  gratefully  welcomed  by  medical 
science,  as  one  of  the  most  inestimable  boons  which  man  could  confer 
upon  his  suffering  fellow-mortals.  Few  now  deny,  and  no  doubt 
ere  long  fewer  and  fewer  will  venture  to  doubt,  that  with  a gene- 
rality as  certain  and  constant,  or  indeed  more  so,  than  we  see  exem- 
plified in  the  action  of  most  other  therapeutic  agents  upon  the 
human  constitution,  etherisation  does  possess  the  desired  and  entire 
effect  of  abolishing  and  annulling  the  pain  following  the  scalpel  and 
saw  of  the  surgeon.  But,  as  I have  already  stated,  a question  of  the 
most  important  moment  remains  behind.  Many  surgeons,  who 

^ The  Princii'iles  of  Surgery,  by  John  Burns,  M.D.,  vol.  i.  p.  502. 

2 Outlines  of  Pathology  and  Practice  of  Medicine, 13.  See  also  pp.  203  and 
317,  on  peritonitis  proving  directly  fatal,  “by  virtue,  probably,  of  the  intense 
and  peculiar  sensation  (of  pain)  it  excites,  acting  as  a powerful  sedative  on  the 
heart.”  On  pain  as  a cause  of  exhaustion  of  nervous  power,  see  also  Dr.  Holland’s 
Medical  Notes  and  Reflections,  p.  618. 

^ Abstract  of  the  Medical  Sciences,  by  Dr.  Banking,  vol.  v.  1847,  p.  383. 


PREVENTION  OF  PAIN  UNNECESSAPvY. 


85 


cannot  gainsay  the  indisputable  effects  of  etlierdnlialation  in  cancel- 
ling the  pains  of  surgical  operations,  still  ardently  maintain  that  this 
admitted  amount  of  present  good  can  only  be  purchased  and  obtained 
by  the  patient,  at  the  hazard  or  certainty  of  a greater  and  dispropor- 
tionate amount  of  future  evil.  In  other  words,  they  allege  and 
maintain  that  the  condition  of  etherisation  is  one  which,  from  its 
marked  powerful  effects  upon  the  economy,  must  produce,  in  some 
cases,  immediately  dangerous  results,  which  must  affect  the  system, 
so  as  to  impede  and  interfere  with  the  condition  of  wounds,  and  the 
recovery  of  patients  from  them,  and  hence  that  it  will  render  opera- 
tions more  perilous  in  their  consequences,  and  more  fatal  in  their 
ultimate  results.  ^ 

The  correctness  or  incorrectness  of  this  last  feasible  and  as- 
suredly most  formidable  objection  to  etherisation  in  surgery,  is  a 
problem  that  no  mere  reasoning  or  mere  opinion  could  ever  certainly 
and  satisfactorily  solve.  The  evidence  of  simple  prejudgment  and 
argument  could  never  perfectly  settle  it,  however  plausible  and 
ingenious  the  grounds  of  the  prejudgment  and  argument  might  be. 
It  is  one  of  those  allegations,  the  accuracy  or  inaccuracy  of  which 
is  a matter  than  can  be  fully  and  finally  determined  by  one  method 
only — namely,  by  an  appeal  to  the  evidence  of  facts,  and  to  the 
evidence  of  facts  alone.  For  the  purpose  of  assisting  in  the  decision 
of  this  question,  I have,  through  the  great  kindness  of  my  profes- 
sional brethren,  collected  the  results  of  above  three  hundred  ampu- 
tations of  the  thigh,  leg,  arm,  and  forearm,  performed  within  the 
last  six  months  upon  patients  in  an  etherised  state,  in  the  civil 
hospitals  of  England,  Scotland,  Ireland,  and  France.  The  statistical 
anatysis  of  these  three  hundred  amputations  with  ether,  and  the  com- 
parison of  their  results  with  the  results  of  various  similar  collections 
of  the  same  amputations  without  ether,  in  the  same  and  in  other 
similar  hospitals,  will,  I believe,  enable  us  to  arrive  at  some  more 
definite  ideas  and  deductions  than  we  are  yet  in  possession  of,  in 
regard  to  the  debated  question  of  the  danger  or  safety  of  etherisa- 
tion in  the  operations  of  surgery. 


86 


DEFENCES  OF  ANESTHESIA. 


CHAPTER  V. 

PAIN  IN  OPERATIONS  FROM  A PATIENT’S  POINT  OF  VIEW.'* 

Edinburgh,  1855. 

My  DEAR  Dr.  Simpson — I have  recently  read,  with  mingled  sadness 
and  surprise,  the  declarations  of  some  surgeons  t^iat  anaesthetics  are 
needless  luxuries,  and  that  unendurable  agony  is  the  best  of  tonics. 
Those  surgeons,  I think,  can  scarcely  have  been  patients  of  their 
brother  surgeons,  and  jest  at  scars  only  because  they  never  felt  a 
wound ; but  if  they  remain  enemies  of  anaesthetics  after  what  you 
have  written,  I despair  of  convincing  them  of  their  utility.  My 
present  object  in  writing  is  not  to  supplement  your  arguments  in 
favour  of  the  administration  of  anaesthetics  to  those  who  are  about 
to  undergo  surgical  operations ; but,  as  one  who  knows  from  per- 
sonal experience  what  operations  were  to  the  patient  before  ether 
or  chloroform  was  employed  anaesthetically,  I am  anxious  to  state 
certain  reasons  in  justification  of  their  use,  which  only  those  who 
suffered  without  their  help  are  in  a condition  to  urge. 

Several  years  ago,  I was  required  to  prepare,  on  very  short 
warning,  for  the  loss  of  a limb  by  amputation.  A painful  disease, 
which  for  a time  had  seemed  likely  to  yield  to  the  remedies  em- 
ployed, suddenly  became  greatly  aggravated,  and  I was  informed  by 
two  surgeons  of  the  highest  skill,  who  were  consulted  on  my  case, 
that  I must  choose  between  death  and  the  sacrifice  of  a limb,  and 
that  my  choice  must  be  promptly  made,  for  my  strength  was  fast 
sinking  under  pain,  sleeplessness,  and  exhaustion. 

I at  once  agreed  to  submit  to  the  operation,  but  asked  a week 
to  prepare  for  it,  not  with  the  slightest  expectation  that  the  disease 
would  take  a favourable  turn  in  the  interval,  or  that  the  anticipated 
horrors  of  the  operation  would  become  less  appalling  by  reflection 
upon  them,  but  simply  because  it  was  so  probable  that  the  operation 
would  be  followed  by  a fatal  issue,  that  I wished  to  prepare  for 

^ Written  by  an  esteemed  professional  colleague  who  holds  a distinguished 
place  in  British  science  and  literature,  and  who,  before  the  days  of  anaesthetics, 
was  himself  the  subject  of  a severe  suigical  operation. — J.  Y.  S. 


PAIN  FROM  A patient’s  POINT  OF  VIEW.  8Y 

death  and  what  lies  beyond  it,  whilst  my  faculties  were  clear  and 
my  emotions  were  comparatively  undisturbed,  for  I knew  well  that 
if  the  operation  were  speedily  followed  by  death,  I should  be  in  a 
condition,  during  the  interval,  in  the  last  degree  unfavourable  to 
making  preparation  for  the  great  change. 

The  week,  so  slow,  and  yet  so  swift  in  its  passage,  at  length 
came  to  an  end,  and  the  morning  of  the  operation  arrived.  There 
were  no  anaBsthetics  in  those  days,  and  I took  no  preparative 
stimulant  or  anodyne  of  any  kind,  unless  two  cups  of  tea,  which 
with  a fragment  of  toast  formed  my  breakfast,  be  considered  such. 

The  operation  was  a more  tedious  one  than  some  which  involve 
much  greater  mutilation.  It  necessitated  cruel  cutting  through 
inflamed  and  morbidly  sensitive  parts,  and  could  not  be  despatched 
by  a few  swift  strokes  of  the  knife.  I do  not  suppose  that  it  was 
more  painful  than  the  majority  of  severe  surgical  operations  are,  but 
I am  not,  I believe,  mistaken  in  thinking  that  it  was  not  less 
painful,  and  this  is  all  that  I wish  to  contend  for. 

Of  the  agony  it  occasioned,  I will  say  nothing.  Suffering  so 
great  as  I underwent  cannot  be  expressed  in  words,  and  thus 
fortunately  cannot  be  recalled.  The  particular  pangs  are  now 
forgotten  ; but  the  black  whirlwind  of  emotion,  the  horror  of  great 
darkness,  and  the  sense  of  desertion  by  God  and  man,  bordering 
close  upon  despair,  which  swept  through  my  mind  and  overwhelmed 
my  heart,  I can  never  forget,  however  gladly  I would  do  so.  Only 
the  wish  to  save  others  some  of  my  sufferings,  makes  me  deliberately 
recall  and  confess  the  anguish  and  humiliation  of  such  a personal 
experience ; nor  can  I find  language  more  sober  or  familiar  than 
that  I have  used  to  express  feelings  which,  happily  for  us  all,  are 
too  rare  as  matters  of  general  experience  to  have  been  shaped  into 
household  words. 

From  all  this  anguish  I should  of  course  have  been  saved  had  I 
been  rendered  insensible  by  ether  or  chloroform,  or  otherwise,  before 
submitting  to  the  operation.  On  that  point,  however,  I do  not 
dwell,  because  it  needs  no  proof,  and  the  testimony  of  the  thousands 
who  have  been  spared  such  experiences  by  the  employment  of 
chloroform,  is  at  hand  to  satisfy  all  who  are  not  determined  not  to 
be  satisfied. 

But  there  are  other  modes  in  which  anesthetics  may  serve 
a patient  than  by  rendering  him  insensible  at  the  period  of  his 
undergoing  a surgical  operation,  and  it  is  to  these  modes  of  service, 
which  may  not  strike  even  tlie  most  humane  and  thoughtful  surgeon, 
62 


88 


DEFENCES  OF  ANESTHESIA. 


and  cannot  be  matters  of  experience  except  to  patients  who  have 
not  taken  anaesthetics,  that  I seek  mainly  to  refer  in  this  letter. 

I am  not  gifted  with  physical  courage.  Physical  courage  I 
understand  to  signify  that  consciousness  of  a power  to  endure  bodily 
agony,  which  accompanies  a certain  temperament.  Its  possessors 
know  from  the  first  instinctively,  and  by  and  by  learn  from 
experience,  that  a blow,  a cut,  a burn,  an  attack  of  toothache,  or  the 
like  infliction  of  injury,  or  onset  of  pain,  can  be  endured  by  them, 
though  unwelcome,  up  to  an  extent  of  considerable  severity,  without 
excessively  incommoding  them  or  exhausting  their  patience.  From 
severe  injuries  and  dangerous  diseases  such  persons  recover,  fortified 
by  the  assurance  that  they  can  bear  without  flinching  what  would 
make  others  complain  loudly,  and  they  are  not  afraid  to  anticipate 
suffering,  believing  that  they  will  be  able  to  bear  it.  This  estimable 
virtue  is  possessed  more  largely  by  men  than  by  women,  and  by 
savage  than  by  civilised  men,  and  may  or  may  not  be  accompanied 
by  moral  courage. 

I belong,  on  the  other  hand,  to  that  large  class,  including  most 
women,  to  whom  cutting,  bruising,  burning,  or  any  similar  physical 
injury,  even  to  a small  extent,  is  a source  of  suffering  never  willingly 
endured,  and  always  anticipated  with  more  or  less  of  apprehension. 
Pain  in  itself  has  nothing  tonic  or  bracing  in  its  effects  upon  such. 
In  its  relation  to  the  body,  it  is  a sheer  and  unmitigated  evil,  and 
every  fresh  attack  of  suffering  only  furnishes  a fresh  proof  of  the 
sensitiveness  possessed  to  pain,  and  increases  the  apprehension  with 
which  its  attacks  are  awaited. 

When  I,  accordingly,  made  up  my  mind  to  submit  to  the  opera- 
tion proposed  to  me,  it  was  with  the  fullest  conviction  that  the  pain 
it  would  occasion  would  far  exceed  my  power  of  patient  tolerance, 
and  I prepared  for  it,  simply  as  for  a dreadful  necessity  from  which 
there  was  no  escape.  I awoke  each  morning  from  troubled  sleep  to 
reconsider  the  whole  reasons  for  and  against  submitting  to  the 
surgeons,  and  by  a painful  effort  reached  again  the  determination 
not  to  draw  back  from  my  first  resolution.  From  all  this  distract- 
ing mental  struggle,  which  reacted  very  injuriously  on  my  bodily 
constitution,  I should  have  been  exempted,  had  I been  able  to  look 
forward  to  the  administration  of  chloroform.  A far  greater  amount 
of  internal  composure  and  serenity  would  then  have  been  mine, 
and  this  mental  peacefulness  would  have  been  a powerful  aid  towards 
sustaining  my  strength,  and  fitting  me  to  bear  the  shock  of  the 
operation. 


TAIN  FROM  A PATIENT’S  POINT  OF  VIEW. 


89 


Again,  I concealed  from  the  relatives  who  w^ere  about  my  sickbed 
what  awaited  me,  knowing  that  an  announcement  of  the  impending 
operation  would  occasion  them  the  greatest  grief,  and  fearing  that 
the  expression  of  that  grief  would  utterly  shake  my  resolution.  On 
the  very  morning  of  the  operation,  I performed  my  toilet  with 
peculiar  pains  and  care,  with  a view  to  disarm  their  apprehensions 
on  hearing  that  the  surgeons  were  to  pay  me  a visit  that  day ; and 
I had  at  least  the  satisfaction  of  afterwards  learning  that  the  ruse 
was  successful.  But  I need  scarcely  say  that  the  mental  tension 
occasioned  by  this  reserve,  and  the  continued  effort  to  play  a part, 
was  a prejudicial  exertion,  and  kept  my  faculties  injuriously  on  the 
strain.  Could  I have  told  my  friends  that  the  operation  would  be 
painless,  we  should  have  conferred  about  it,  and  they  and  I would 
have  been  saved  much  distress. 

Further  ; during  the  operation,  in  spite  of  the  pain  it  occasioned, 
my  senses  were  preternaturally  acute,  as  I have  been  told  they  gene- 
rally are  in  patients  in  such  circumstances.  I watched  all  that  the 
surgeons  did  with  a fascinated  intensity.  I still  recall  with  unwel- 
come vividness  the  spreading  out  of  the  instruments ; the  twisting 
of  the  tourniquet ; the  first  incision ; the  fingering  of  the  sawed 
bone ; the  sponge  pressed  on  the  flap ; the  tying  of  the  blood 
vessels ; the  stitching  of  the  skin ; and  the  bloody  dismembered 
limb  lying  on  the  floor. 

Those  are  not  pleasant  remembrances.  For  a long  time  they 
haunted  me,  and  even  now  they  are  easily  resuscitated  j and  though 
they  cannot  bring  back  the  suffering  attending  the  events  which 
gave  them  a place  in  my  memory,  they  can  occasion  a suffering  of 
their  own,  and  be  the  cause  of  a disquiet  which  favours  neither 
mental  nor  bodily  health.  From  memories  of  this  kind,  those 
subjects  of  operations  who  receive  chloroform  are  of  course  free ; 
and  could  I,  even  now,  by  some  Lethean  draught  erase  the  re- 
membrances I speak  of,  I would  drink  it,  for  they  are  easily  brought 
back,  and  they  are  never  welcome. 

How  far  my  experiences  agree  with  those  of  others  who  have 
undergone  similar  operations  I do  not  know,  but  except  that  I may 
have  a more  active  and  roving  fancy  or  imagination  than  some  of 
my  fellow-sufferers,  I cannot  doubt  that  my  experiences  are  not 
singular. 

That  the  dread  of  pain  keeps  many  a patient  from  submitting  to 
operations  which  would  save  life,  is  notorious  j but  the  dread  of  a 
particular  mode  of  inflicting  pain  is  a more  dissuasive  motive  with 


90 


DEFENCES  OF  ANAESTHESIA. 


many  than  the  dread  of  the  pain  so  inflicted.  Hundreds  every  day 
endure  the  great  torture  of  toothache,  rather  than  the  small  torture 
of  the  extraction  of  the  tooth.  Women,  in  particular,  suffer  pro- 
longed agonies  for  months,  rather  than  submit  to  a fraction  of  the 
same  amount  of  pain  at  a surgeon’s  hand,  because,  as  produced  by 
him,  it  takes  the  form  of  an  incision  with  a sharp  knife ; and  a red- 
hot  iron  is  held  in  such  horror  by  most  persons,  that,  rather  than  be 
touched  by  it,  though  the  pain  it  occasions  is  but  momentary,  they 
will  endure  the  application  of  chemical  caustics  which  occasion 
torture  for  hours. 

Anjesthetics  render  all  such  persons  as  great  a service  by  render- 
ing them  insensible  to  the  accompaniments  of  an  operation,  as  by 
rendering  them  insensible  to  its  pain.  It  is  true  that  if  they  felt  no 
l)ain,  they  might  be  as  calm  and  even  curious  spectators  of  the  dis- 
membering of  themselves  as  in  dreams  all  men  are,  of  what  in  waking 
life  would  be  the  most  agonising  realities.  But  it  is  not  less  true,  that 
sufferings  equal  to  those  of  the  severest  operations  are  experienced 
by  patients,  in  the  course  of  acute  or  aggravated  maladies,  without 
being  followed  by  the  crushing  effect  of  the  operations  which  they 
rival  in  power  to  occasion  agony ; and  surely  this  is  not  to  be 
wondered  at.  Before  the  days  of  anaesthetics,  a patient  preparing 
for  an  operation  was  like  a condemned  criminal  preparing  for  execii- 
tion.  He  counted  the  days  till  the  appointed  day  came.  He  counted 
the  hours  of  that  day  till  the  appointed  hour  came.  He  listened  for 
the  echo  on  the  street  of  the  surgeon’s  carriage.  He  watched  for  his 
pull  at  the  door-bell ; for  his  foot  on  the  stair ; for  his  step  in  the 
room ; for  the  production  of  his  dreaded  instruments  ; for  his  few 
grave  words,  and  his  last  preparations  before  beginning.  And  then 
he  surrendered  his  liberty,  and  revolting  at  the  necessity,  submitted 
to  be  held  or  bound,  and  helplessly  gave  himself  up  to  the  cruel 
knife.  The  excitement,  disquiet,  and  exhaustion  thus  occasioned, 
could  not  but  greatly  aggravate  the  evil  effects  of  the  operation, 
which  fell  upon  a physical  frame  predisposed  to  magnify,  not  to 
repel,  its  severity.  To  make  a patient  incognisant  of  the  surgeon’s 
proceedings,  and  unable  to  recall  the  details  of  an  operation,  is 
assuredly  to  save  him  from  much  present  and  much  future  self- 
torture,  and  to  give  to  him  thereby  a much  greater  likelihood  of 
recovery. 

Further;  the  horror  with  which  attached  relatives  regard  the 
prospect  of  operations  on  those  very  dear  to  them — a horror  far 
surpassing  that  with  which  they  w’ould,  in  many  cases,  hear  of  such 


PAIN  FROM  A patient’s  POINT  OF  VIEW. 


91 


operations  awaiting  themselves — leads  them  often  to  dissuade  their 
friends  from  submitting  to  surgical  interference.  The  issue  in  too 
many  cases  is,  that  the  poor  patient  listens,  though  but  half-con- 
vinced, to  their  arguments ; tries  doctor  after  doctor,  and  remedy 
after  remedy,  only  to  be  compelled  in  the  end,  after  weeks  or  months 
of  prolonged  suffering,  to  submit  to  the  operation.  The  prospects  of 
recovery,  however,  in  such  cases,  are  too  often  immensely  lessened 
by  the  physical  exhaustion  and  enfeebled  general  health  which  have 
resulted  from  the  delay.  The  knowledge,  on  the  other  hand,  that  a 
mother,  a sister,  a wife,  or  a child,  will  be  carried  unconsciously 
through  a severe  operation,  cannot  but  rob  it  of  half  its  horrors  in 
the  eyes  of  friends,  and  will  make  them  often  the  allies  rather  than 
the  opponents  of  the  surgeon,  and  keep  them  from  showing  the  false 
kindness  to  their  relatives,  of  dissuading  them  from  submitting  to 
the  only  treatment  which  promises  a cure. 

The  sum  you  will  perceive  of  what  I have  been  urging,  is,  that 
the  unconsciousness  of  the  patient  secured  by  amesthetics  is  scarcely 
less  important  than  the  painlessness  with  which  tliey  permit  injuries 
to  be  inflicted  on  him.  To  steep  his  senses  in  forgetfulness,  and 
throw  the  whole  intellectual  machine  out  of  action,  when,  if  allowed 
to  work,  it  only  moves  with  a rapidity  and  irregularity  which 
threaten  its  integrity,  and  permanently  injure  it,  is  to  do  him  a 
service,  second  only  to  that  of  saving  him  from  suffering.  And  to 
make  it  impossible  for  him  to  recall  a scene  of  horror,  and  torture 
himself  by  going  over  and  over  all  its  incidents  again  and  again,  is 
also  to  do  him  a signal  service.  Nor  need  more  be  said  concerning 
the  service  done  to  his  friends. 

I plead  therefore  for  the  administration  of  anaesthetics  on  the 
grounds  enumerated.  I fear  you  may  think  my  confessions  exagger- 
ated, but  I can  most  honestly  declare  that  they  are  not.  AYhen  I 
first  heard  that  anaesthetics  had  been  discovered,  I could  not  and 
would  not  believe  it.  I have  since  thanked  God  many  a time, 
that  He  has  put  it  into  your  heart,  and  into  that  of  other  wise  and 
humane  men,  to  devise  so  simple  and  so  safe  a way  of  lessen- 
ing pain. 

As  for  the  fear  entertained  by  some,  that  the  moral  good  which 
accrues  from  suffering,  and  is  intended  by  the  Ruler  of  all  to  be 
secured  by  it,  will  be  lost  if  agony  is  evaded  by  sufferers  having 
recourse  to  ancesthetics,  we  may  surely  leave  that  to  the  disposal  of 
Him  who  does  all  things  well.  The  best  answer  to  such  complaints 


92 


DEFENCES  OF  ANAESTHESIA. 


I have  heard,  was  that  given  by  an  excellent  old  lady  to  another, 
who  was  doubting  whether  any  of  the  daughters  of  Eve  were  at 
liberty  to  lessen  by  anassthetics  the  pangs  of  child-hearing  : “ You 
need  not  be  afraid,”  said  the  wiser  lady,  “ that  there  will  not  he 
enough  of  suffering  in  the  world.” 

I think  not ; but  may  you  he  honoured  still  further  to  reduce 
its  sum. — Yours  most  truly, 


An  Old  Patient. 


COMPAKATIVE  STATISTICS. 


93 


CHAPTER  VI. 

DOES  ANAESTHESIA  INCREASE  OR  DECREASE  THE  MORTALITY 
ATTENDANT  UPON  SURGICAL  OPERATIONS] 

“ Why  dost  thou  whet  thy  knife  so  earnestly  ? 

Shylock  must  he  merciful. 

On  what  compulsion  must  I ? Tell  me  that.” 

Shakespeare’s  Merchant  of  Venice. 

Edinburgh,  April  1848. 

Shortly  after  an£esthesia  began  to  be  employed  in  surgery,  its 
alleged  beneficial  or  baneful  effects  were  keenly  discussed  among  the 
members  of  the  profession ; and  principally,  or  entirely,  upon  the 
results  of  individual  or  isolated  cases.  Some  eagerly  and  stoutly 
doubted,  in  toto,  the  possibility  of  making  operations  painless ; and 
many  who  admitted  its  possibility,  denied  altogether  its  proimiety, 
on  the  alleged  ground  of  its  increasing  the  general  subsequent  dangers 
of  the  patient,  inducing  a variety  of  alleged  morbid  states  and  lesions, 
and  adding,  on  the  whole,  to  the  fatality  of  operative  surgery. 

Amidst  the  many  conflicting  and  contradictory  assertions  that 
were  uttered  on  these  points,  I became  convinced  that  there  was 
only  one  method  of  arriving  at  the  truth — viz.  by  instituting  a statis- 
tical investigation,  upon  as  large  a scale  as  possible,  into  the  results 
of  the  practice,  and  thus  ascertaining  whether,  out  of  an  extensive 
series  of  operations  performed  with  and  without  angesthesia,  the 
mortality  was  greater  or  was  less  when  the  patients  were  operated 
on  in  a narcotised  and  anaisthetic  state,  than  when  they  were 
operated  on  in  a waking  and  aesthetic  state. 

The  first  difficulty  to  be  encountered  in  such  an  inquiry  was  the 
difficulty  of  obtaining  a proper  field  and  standard  for  the  proposed 
comparison.  But  first  of  all,  it  was  evident  that  the  comparison, 
whatever  it  might  be,  could  only  be  properly  instituted  between 
patients  operated  on  in  public  hospitals,  with  and  without  anaes- 
thesia. For  we  had  nowhere  published,  nor  did  it  seem  j30ssible  to 
obtain,  any  adequate  comparative  returns  of  the  results  of  operations 


94 


DEFENCES  OF  ANiESTHESIA. 


from  the  surgical  practice  of  private  practitioners.  Besides,  hospital 
returns  were  preferable  in  this  respect,  that  there  existed  on  the 
whole,  everywhere,  undoubtedly  a far  greater  uniformity  between 
the  hygienic  and  other  collateral  circumstances  of  patients  operated 
on  in  hospital  than  in  private  practice.  Secondly,  however,  it  was 
further  evident,  that  in  seeking  and  fixing  upon  a criterion  by  which 
we  could  compare  the  statistical  results  of  surgical  operations  for- 
merly performed  without  anaesthesia,  with  those  now  performed  upon 
anaesthetised  patients,  it  was  improper  and  impossible  to  institute 
the  comparison  between  all  operations  and  reports  of  operations  in 
hospitals ; for  the  severity  and  danger  of  the  operations  performed 
in,  and  reported  from,  different  hospitals,  differed  immensely  in  their 
nature,  and  consequently  in  their  results.  In  order,  therefore,  to 
obtain  the  primary  requisite  for  a correct  statistical  inquiry — of 
having  data  of  a similar  kind  and  character  for  the  proposed  testing 
and  comparison — it  was  necessary  to  select  and  contrast  the  result 
of  some  one  operation  without  ether,  with  the  results  of  the  same 
one  operation  with  ether.  With  this  view  I selected  the  larger 
amputations  of  the  limbs  as  the  fittest  field  on  which  to  conduct  the 
proposed  investigation ; and  I restricted  myself  to  hospital  amputa- 
tions of  the  thigh,  leg,  arm,  and  forearm,  on  account  of  their  being 
everywhere  performed  in  almost  the  same  manner,  for  the  same 
causes,  under  the  same  circumstances,  and  on  the  same  class  of  sub- 
jects ; and  because  there  already  existed  extensive  published  re- 
searches, by  Phillips,  Lawrie,  and  Malgaigne,  into  their  absolute 
mortality,  when  performed  under  ordinary  circumstances  and  without 
anaesthesia,  to  aid  us  in  satisfactorily  determining  the  nature  of  the 
results  of  the  new  practice  of  operating  upon  patients  in  an  anaes- 
thetic state. 

Having  thus  fixed  upon  the  mode  of  inquiry,  I proceeded  to 
apply  for  returns  from  all  the  surgical  hospitals  of  Great  Britain  and 
Ireland  that  I could  hear  of,  as  likely  to  have  employed  anaesthesia 
in  amputations.  And  I feel  it  quite  impossible  to  return  thanks,  in 
any  adequate  terms,  for  the  very  great  politeness  and  kindness  with 
which  my  inquiries  were  answered  on  all  hands.^  In  some  hospitals 

^ In  my  letter  of  application,  I stated,  that  “the  effects,  whether  favourable 
or  unfavourable,  of  an.nesthesia  upon  the  ultimate  recoveries  of  patients  from 
surgical  operations  is  still  a matter  of  much  doubt  and  uncertainty.  We  have  as 
yet  had  no  proper  collection  of  data  to  ascertain  whether  the  mortality  of  opera- 
tions has  been  increased  or  not  by  patients  being  placed  under  the  influence  of 
ether  at  the  period  of  their  performance.  In  order  to  determine  as  far  as  possible 
this  important  point,  I have  been  induced  to  undertake  the  statistical  investiga- 


COMPARATIVE  STATISTICS. 


95 


anaesthesia  had  not  been  tried,  and  I was  consequently  furnished 
with  no  data ; in  others  in  which  it  was  used,  my  correspondents 
were  quite  at  issue  about  its  propriety ; many  were  doubtful ; 
some  expressed  themselves  strongly  against  it,  and  others  strongly 
for  it.  But  I was  principally  anxious  to  obtain  the  total  results, 
believing  that  they  would  decide  the  question  far  more  certainly 
than  any  individual  experience  or  individual  opinion  could.  In 
Table  No.  I.  (see  pp.  9G  and  97),  these  results  are  given  in  a 
detailed  form,  with  the  names  of  the  gentlemen  who  kindy  reported 
each  return  to  me.^ 


tion  of  tlie  results  of  the  larger  amputations  in  cases  ■where  anaesthesia  "was 
employed  at  the  time  of  operation.  Amputations  have  been  selected  for  this 
purpose  in  preference  to  other  operations,  because  they  are,  under  all  common 
circumstances,  nearly  and  everywhere  alike,  and  because  the  general  average  mor- 
tality accompanying  most  of  the  greater  arniuitations  is  already  known,  from  tlie 
inquiries  of  Phillips,  Lawrie,  and  others,  and  thus  a ready  standard  of  comparison 
is  afforded  us.  You  w'ould,  therefore,  oblige  me  by  filling  up  the  following  table 
■with  any  results,  however  few  in  number,  of  amputations  in  which  ether  was  used 
in  your  hospital.  I especially  wish  to  know  all  the  deaths  as  well  as  all  the 
recoveries  in  these  operations  ; and  by  thus  collating,  on  the  whole,  a large  body 
of  statistical  data,  I hope  to  be  able  to  arrive  at  the  same  general  results.” 


Copy  of  Foem  of  Table  sent. — “Results  of  Amputations  pebfobmed  upon 
Patients  in  an  Etherised  State  in  the Hospital.” 


Seat  of  Amiiutation. 

Primary  or  for  Injury. 

Secondary  or  for  Disease,  j 

Total  No. 
of  Cases. 

Total  No. 
of  Deatlis. 

Total  No. 
of  Cases. 

Total  No. 
of  Deaths. 

Amputation  of  Thigh  . . 

Amputation  of  Leg . . . 

Amputation  of  Arm  . 
Amputation  of  Forearm  . 

Total  . . 

1 

1 

i 

It  may  be  proper  to  remark  that,  in  answer  to  the  returns,  I had  the  results  of 
twenty-four  amputations  of  the  forearm  sent  me,  which  are  not  included  in  the 
subsequent  remarks  in  the  text.  Out  of  these  twenty-four  amputations  ten  Avere 
primary,  with  one  death,  and  fourteen  secondary,  with  two  deaths.  I have  omitted 
them  in  the  text,  in  consequence  of  finding  that  Mr.  Phillips,  in  his  standard  of 
amputations,  confines  his  returns  to  those  of  the  thigh,  leg,  and  aim,  and  does  not 
include  those  of  the  forearm. 

^ In  No.  49  of  the  Table,  the  name  of  the  hospital  is  not  mentioned,  as  my 
correspondent  unfortunately  omitted  to  date  his  return.  The  Paris  hospital 
returns  of  twenty-t'wo  cases  (No.  40)  are  distributed  according  to  the  standard  of 
Malgaigne  ; Dr.  Burguieres,  in  a note  to  me,  having  stated  that  he  was  unable  to 
give  the  exact  number  of  these  amputations  Avhich  were  respectively  primary  and 
secondary. 


96 


DEFENCES  OF  ANESTHESIA. 


No.  L — Table  showing,  in  detail,  the  number  of  Individual 

302  Patients 


— 

Amputation  of  Thigh. 

Name  of 

Primary. 

Secondary. 

No. 

Name  of  Hospital. 

Reporter. 

Cases. 

Deaths. 

Cases. 

Deaths. 

1 

Aberdeen  Eoj^al  Infirmary  . | 

Dr.  Keith  and  ) 
Dr.  Macintosh  J 

2 

1 

2 

Bedford  General  Infirmary  . 

Mr.  Hurst 

3 

0 

3 

Birmingham  General  Infirmary 

Mr.  Amphlett  . 

1 

0 

4 

Birmingham  Queen’s  Hospital 

Dr.  Wright 

1 

0 

5 

Bristol,  General  Hospital  . | 

Dr.  Lansdowne  ) 
and  Mr.  Mason  j 

3 

0 

6 

Bristol  Infirmary 

Mr.  Morgan 

i’ 

1 

1 

7 

Belfast  Hospital 

Mr.  Moore 

1 

1 

1 

8 

Cumberland  Infirmary 

Mr.  Page  . 

2 

1 

9 

Chester  Infirmary 

Mr.  Harrison  . 

1 

10 

Cork  South  Infirmary 

Dr.  Tanner 

3 

0 

11 

Dundee  Infirmary 

Dr.  Monro 

i 

1 

12 

Dumfries  Infirmary  . 

Mr.  Borthwick 

13 

Derbyshire  General  Infirmary 

Mr.  Fox  . 

i 

’6 

14 

Devon  and  Exeter  Hospital 

Mr.  James 

2 

0 

15 

Dublin  Mercer  Hospital 

Dr.  Jamieson  . 

1 

1 

16 

Dublin  Richmond  Surg.  Hosp. 

Dr.  Hamilton  . 

i’ 

3 

1 

17 

Edinburgh  Infirmary  . 

Mr.  Miller 

1* 

2 

0 

18 

Edinburgh  Infirmary  . 

Dr.  Duncan 

2 

2 

4 

1 

19 

Elgin  Infirmary 

Dr.  Paul  . 

20 

Glasgow  Hospital  . . | 

Dr.  OiT  and  Dr.  ) 
Steel  . . ) 

8 

4 

21 

Hereford  Infirmary 

Mr.  Wandby  . 

i 

3 

0 

22 

Hull  General  Infirmary 

Mr.  Craven 

0 

1 

1 

23 

Hants,  Royal  South  Infirmary 

Dr.  Bullar 

24 

Ipswich  Hospital 

Dr.  Durrant 

3 

’0 

25 

Leeds  Infirmary 

Mr.  Hey  . 

i 

26 

London  Hospital 

Mr.  Curling 

0 

’4 

'0 

27 

Lond.,  St.  Bartholomew’s  Hos. 

Mr.  Haig . 

2 

1 

6 

3 

28 

London,  Univ.  College  Hosp.  | 

Mr.  Liston  and  ) 
Mr.  Cadge  . j 

2 

1 

5 

0 

29 

London,  King’s  College  Hosp. 

Mr.  Fergusson  . 

1 

0 

30 

London,  St.  George’s  Hospital 

Dr.  Snow 

... 

12 

2 

31 

London,  Middlesex  Hospital 

Mr.  Shaw 

5 

0 

32 

London,  Charing  Cross  Hosp. 

Mr.  Avery 

l’ 

o’ 

2 

1 

33 

London,  Westminster  Hosintal 

Dr.  Bird  . 

4 

0 

34 

Leicester  Infirmary  . 

Mr.  Paget 

2 

0 

35 

Liverpool  Northern  Hospital 

Dr.  Bainbrigge  . 

c»  < 

3 

’2 

36 

Liverpool  Southern  Hospital 

Mr.  Morris 

l< . 

1 

0 

37 

Manchester  Royal  Infirmary 

Dr.  Reid  . 

2 

1 

38 

Newcastle  Infirmary  . 

Mr.  Greenhow  . 

... 

39 

Nottingham  General  Hospital 

Mr.  Wright 

’3 

0 

40 

Paris  Hospitals  . 

Dr.  Burguieres  . 

3 

2 

7 

2 

41 

Perth  Infirmary  . 

Dr.  M‘Farlane  . 

4 

2 

1 

0 

42 

Sussex  County  Hospital 

Mr.  Parson 

1 

0 

3 

0 

43 

Staffordshire,  North  Infirmary 

Mr.  Turner 

2 

0 

44 

Sheffield  General  Infirmary  . 

Mr.  Jackson 

3 

0 

45 

Salisbury  Infirmary  .. 

Mr.  Young 

4 

2 

46 

Stockport  Infirmary  . 

Mr.  Rayner 

47 

Winchester  County  Hospital 

Mr.  Wickham  . 

’3 

0 

48 

Worcester  Infirmary  . 

Mr.  Sheppard  . 

1 

’i’ 

4 

0 

49 

Mr.  Stocker 

1 

0 

1 

0 

Total 

24 

12 

121 

25 

COMPARATIVE  STATISTICS. 


97 


Amputations  and  their  Eesults,  in  different  Hospitals,  upon 
UNDER  Etherisation. 


Amputation  of  Leg. 

Amputation  of  Arm. 

TOTAL 

CASES. 

Primary. 

Secondary. 

Primary. 

Secondary. 

Primary. 

Secondary. 

09 

09 

09 

W 

09 

W 

09 

a> 

O) 

09 

"rt 

a 

09 

rt 

X 

"c? 

c3 

0) 

Cj 

a' 

ce 

o 

0 

Q 

Q 

0 

p 

0 

C 

c 

... 

5 

0 

... 

• •• 

7 

1 

... 

1 

0 

4 

0 

2 

0 

i 

6 

2 

0 

2 

o’ 

4 

0 

I 

0 

3 

0 

1 

0 

4 

0 

... 

3 

0 

... 

... 

6 

0 

• •• 

1 

1 

i 

0 

T 

0 

1 

’i’ 

3 

1 

... 

2 

0 

1 

6 

1 

0 

4 

1 

1 

0 

1 

0 

i 

0 

2 

1 

1 

0 

*2 

0’ 

5 

1 

1 

0 

1 

0 

1 

0 

1 

0 

1 

1 

i 

0 

. . • 

1 

0 

1 

’0 

... 

1 

6 

3 

0 

1 

1 

• •• 

1 

i 

... 

4 

2 

i 

i 

1 

i 

3 

1 

i 

V 

3 

0 

3 

2 

7 

1 

i 

0 

1 

0 

5 

1 

5 

2 

2 

0 

4 

3 

7 

1 

17 

» 1 

.... 

3 

0 ' 

3 

i’ 

2 

0’ 

0’ 

1 

0 

'5 

’i’ 

4 

1 ; 

2 

0 

1 

0 

1 

1 

1 

0 

3 

1 

3 

0 

i’ 

0 

T 

0 

i’ 

0 

1 

0 

3 

2 

1 

0 

4 

2 

5 

0 

2 

1 

4 

1 

2* 

1’ 

1' 

0 

6 

3 

11 

4 

5 

1 

1 

1 

2 

1 

11 

2 

1 

0 

... 

2 

0 

7 

0 

• . • 

T 

0 

20 

3 

1 

0’ 

1 

1 

1 

0 

T 

*0 

7 

1 

1 

0 

1 

0 

3 

1 

i’ 

0’ 

1 

0 

6 

0 

1 

0 

’2 

’0 

1 

0 

4 

3 

2’ 

1 

9 

6 

1 

0 

T 

0 

1 

0 

2 

0 

2 

0 

2* 

1 

4 

2 

2 

2 

1' 

0’ 

3 

’2 

1 

0 

1’ 

0’ 

1 

1 

2 

1 

’4 

0 

;3 

1 

5 

2 

2 

1 

2 

i’ 

8 

4 

14 

5 

4 

2 

1 

0 

.‘3 

i’ 

i’ 

0 

i’ 

6 

5 

1 

4 

0 

... 

2 

0 

4 

0 

... 

2 

0 

. • « 

’2 

0 

• • • 

7 

0 

3 

0 

7 

2 

... 

2 

0 

2 

0 

2 

0 

0 

5 

0 

*4 

0’ 

*2 

i’ 

3 

’2 

8 

0 

i* 

6 

2 

0 

1 

0 

32  ! 

9 

81 

13 

17 

4 

27 

« 1 

73 

25  1 

229 

98 


DEFENCES  OF  ANAESTHESIA. 


GENERAL  MORTALITY  OF  AMPUTATIONS  OF  THE  THIGH,  LEG,  AND 
ARM,  WITHOUT  ANaESTHESIA. 

Before  attempting  to  determine  whether  the  results  in  these 
anaesthetic  amputations  (Table  Xo.  I.)  are,  or  are  not  favourable 
to  the  adoption  of  Anaesthesia  in  Surgery,  let  me  in  the  first  place 
state  the  results  of  the  previous  investigations  that  have  been  pub- 
lished by  Phillips,  Lawrie,  and  Malgaigne,  relating  to  the  mortality 
of  these  same  amputations,  when  the  same  operations  were  performed 
without  anaesthesia.  In  the  year  1837,  Mr.  Benjamin  Phillips 
brought  before  the  Royal  Medico-Chirurgical  Society  of  London  a 
communication  ^ on  the  results  of  amputation  of  the  thigh,  leg,  and 
arm,  in  different  countries.  From  the  collection  of  cases  which  he 
laid  before  the  society,  Mr.  Phillips  concluded  that  the  general  mor- 
tality of  these  larger  amputations  amounted  to  23  deaths  in  the  100 
operations.  The  correctness,  however,  of  his  conclusions  was  called 
in  question  by  the  publishing  committee  of  the  society,  on  the  idea 
that  the  alleged  mortality  was  too  great,  and  he  was  recommended 
to  investigate  the  subject  more  fully  before  proceeding  to  publish  his 
observations.  Farther  inquiry  served  only  to  satisfy  him  that  his 
previous  results  were  understated  rather  than  overstated. 

Subsequently,  in  1844,  Mr.  Phillips  published  a table  of  a stiU 
more  extensive  series  of  cases.^  This  collection,  however,  includes 
the  results  of  private  as  well  as  of  hospital  practice.  “ They  are,”  says 
Mr.  Phillips,  “ the  whole,  so  far  as  I know,  of  the  cases  of  amputa- 
tion recorded  in  the  periodical  literature  of  this  and  other  countries 
during  the  present  century.  I by  no  means,”  Mr.  Phillips  adds, 
think  that  the  results  furnished  by  such  data  will  fairly  represent 
the  mortality.  I believe  it  will  be  understated,  because  successful 
cases  are  more  likely  than  unsuccessful  ones  to  find  their  way  into 
print.” 

The  Table  (No.  II.)  extracted  from  Mr.  Phillips’s  second  paper, 
shows  in  a summary  way  the  results  which  he  obtained  from  these 
sources. 

^ Observations  on  the  Results  of  Amputation  in  different  Countries.  Medical 
Gazette,  vol.  xxii.  1837-38,  p.  457. 

2 Mcdiccd  Gazette,  vol.  xxxiii.  1843-44,  p.  804. 


COMPAKATIVE  STATISTICS. 


99 


No.  11. — Table  op  the  Mortality  op  1369  Cases  of  Amputation  of 
THE  Thigh,  Leg,  and  Arm. 


Seat  of 
Amputation. 

Primary. 

Secondary. 

No.  of 
Cases. 

No.  of 
Deaths. 

Percentage 
of  Deaths. 

No.  of 
Cases. 

No.  of 
Deaths. 

Percentage 
of  Deaths. 

Thigh  . . . 

245 

176 

72 

415 

87 

21 

Leg  . . . 

204 

88 

43 

231 

61 

27 

Arm  . . . 

164 

49 

29 

110 

26 

24  1 

1 

Total  . . 

613 

313 

51 

756 

174 

23  ! 

In  the  year  1840,  Dr.  Lawrie  of  Glasgow  published  an  excellent 
paper  ^ on  the  results  of  amputations,  with  tables  showing  the  rate 
of  mortality  from  amputation  in  the  Glasgow  Hospital,  from  the 
period  of  its  foundation  in  1794  down  to  1839.  Dr.  Lawrie’s  in- 
quiries yielded  an  average  mortality  greater  than  that  of  Mr. 
Phillips,  being  as  high  as  36  per  cent.  The  following  table,  made 
from  data  in  Mr.  Lawrie’s  paper,  contains  the  results  of  amputation 
of  the  thigh,  leg,  and  arm,  in  the  Glasgow  Hospital : — 


No.  III. — Table  op  the  Mortality  of  242  Amputations  of  the  Thigh, 
Leg,  AND  Arm,  in  the  Glasgow  Hospital,  from  1794  to  1839. 


Primary. 

Secondary. 

ocat  01 

Amputation. 

No.  of 

No.  of 

Percentage 

I No.  of 

No.  of 

Percentage 

Cases. 

Deaths. 

of  Deaths. 

Cases. 

Deaths. 

of  Deaths. 

Thigh.  . . 

35 

27 

77  i 

92 

19 

20 

Leg  . . . 

27 

18 

66  ! 

35 

12 

34 

Ann  . . . 

36 

18 

50  1 

17 

3 

17  j 

Total . . 

98 

i 

63 

i 

64 

144 

34 

23  j 

In  1842  a valuable  series  of  papers  on  the  statistics  of  amputa- 
tions was  published  by  Professor  Malgaigne  in  the  A rchives  Generales 
de  Medecine,  his  data  being  derived  from  the  reports  of  the  Parisian 
hospitals.  In  these  papers,  Malgaigne  enters  largely  upon  the  sub- 
ject of  the  mortality  of  amputations.  The  following  table,  compiled 
from  data  in  his  returns,^  exhibits  a mortality  still  higher  than  that 
of  the  Glasgow  Hospital. 

^ On  the  Eesults  of  Amputations.  Medical  Gazette,  vol.  xxvii.  1841^  p-  394. 

^ Archives  Generates  de  MMccine,  vol.  Iviii.  1842,  p.  40. 


100 


DEFENCES  OF  ANAESTHESIA. 


No.  lY.  — Table  op  the  Mortality  op  484  Amputations  of  the 
Thigh,  Leg,  and  Arm,  in  the  Parisian  Hospitals,  prom  1836 
TO  1841. 


Seat  of 
Amputation. 

Primary.  j 

Secondary. 

No.  of 
Cases. 

No.  of 
Deaths. 

Percentage 
of  Deaths. 

No.  of 
Cases. 

No.  of 
Deaths. 

Percentage 
of  Deaths,  j 

Tliigli  . . . 

48 

34 

70 

153 

92 

60 

Leg  . . . 

80 

51 

63 

112 

55 

49 

Arm.  . 

30 

17 

56 

61 

24 

39 

Total  . . 

158 

102 

64 

326 

171 

52  1 

1 

These  three  tables  of  large  collections  of  cases  by  Phillips, 
Lawrie,  and  Malgaigne,  may  be  properly  considered  as  giving  a 
correct  idea  of  the  general  mortality  of  these  amputations  in  hos- 
pital practice,  and  may  be  used  with  justice  as  subjects  of  com- 
parison with  any  series  of  cases  similar  to  them-  in  the  whole  series 
of  circumstances,  except  that  one  whose  influence  upon  the  results 
is  to  be  decided.  After,  however,  I began  to  collect  the  results  and 
mortality  of  the  same  amputations  upon  patients  in  an  anaesthetised 
state  from  various  British  and  other  hospitals,  it  was  objected  to  the 
inquiry  that  it  would  be  unsatisfactory  in  two  respects — viz.,  that  the 
amputations  compared  were  possibly  performed  in  different  classes 
of  hospitals,  and  at  dates  so  different  that  I did  not  consider  in  my 
investigation  the  changes  and  improvements  which  might  possibly 
have  been  introduced  into  the  very  methods  of  operating. 

In  order,  then,  at  once  to  enlarge  the  basis  of  data  for  com- 
parison, and  to  obtain  a series  of  cases  still  more  exactly  similar  to 
the  collection  of  anaesthetic  amputations  which  I was  making,  I pro- 
cured from  various  British  hospitals,  through  the  kindness  of  different 
correspondents,  and  from  published  data,  returns  of  the  latest  ampu- 
tations that  had  been  performed  in  them  immediately  previous  to 
the  introduction  of  anaesthesia.  These  returns  are  given  in  detail 
on  page  101.  All  of  the  operations  have  been  performed  within 
the  eight  years,  from  1839  to  1846  inclusive.  By  having  this  col- 
lection of  cases  as  an  additional  standard,  I hoped  to  avoid  all  cavil 
on  the  ground  of  any  supposed  difference  in  the  time,  and  other 
collateral  circumstances,  in  which  the  compared  operations  were 
performed. 


•Table  showing,  in  detail,  the  kesults  of  618  Amputations,  in  30  different  British  Hospitals, 

IMMEDIATELY  BEFORE  THE  INTRODUCTION  OF  ANAESTHESIA. 


COMPARATIVE  STATISTICS.  101 


TOTAL  CASES. 

Secondary. 

•siUBoa 

«OOCOr-IOr-l'-<<M(MOOe'1l^r~0  •OCOOi-i'OOvOOCO'lr-tOOOr^. 

•S8SB0 

^=000,0000^^^0000,  .o;^oo^^o,o,oi-=o^oo 

i 

Primary.  I 

•sillBaa 

lO  -O  *1000  • •rHiOi-'Oi-HOr-COr-t'^O'^C'lt- 

•S9SBO 

O .O  .WrHO,  . .Ot^rH0,OO0,^Of.O^OO  .,,0^=0000 

i 

Amputation  of  Arm. 

f 

1 

•SIDB9(I 

0 

1 

j [*«  . .rHrH  O} 

Primary. 

•si^naa 

o -o  -o  -o  • .ot,<  •':,(poooooooo  -o,  -r-ioo 

•S3SB0 

O ; =0  ; CO  .0,  • • =0  0 . t-  ^ 0,  rH  00  =0  rH  =0  0,  • O • CO  ^ 0,  • 01  » |^ 

Amputation  of  Leg. 

1 Secondary. 

•si^naa 

.rH  • •00000(N0i-H'^  • • -r-HC-IOC-l  •COClOr-lO  -OO 

•S9SB0 

0 -O,  • .coo,  OlO-^l^r-lOM  . • ■•Ot-COCOr-l  .cocoj  0 

Primary.  I 

■siRUoa 

<M  -O  -o  • • • .i-HCOrHiOiOO  -OOi-HOr-IrH^I  -r-lCq  -OOrH 

•S9SUG 

'CM  -CO  • • • -r-iCOrHi-H-^tMCO  ' Cl  CO  -COr-HrH 

8 

Amputation  of  Thigh. 

Secondary.! 

•sluuaa 

(NOC^rHOrHi-HrHC^OCOC^^DCOO  -G^liOnoOOOO 

■3 

j •S9STJO 

t-CO^O,  00,Tt<OiOO,  OCOj^O,0,  -Ot-OCOOO  .OMOqCOCr-IOr-t 

Primary. 

•sinT39a 

CO  ;0  -OO  . ; ;OCO  -OCO  -rH  .r-,COOCOrHCO  .0,00,  • • • 

•S9S'Ba 

::::S  ;o,>oo,orHf.  .0,0,0,  : : ; 1 « 

Name  of 
Reporter. 

Dr.  Macintosh 
Dr.  Rogers 
i\Ir.  Morgan 

Mr.  Mason 

Mr.  Mav  . 

Mr.  Builen 

Mr.  Page  . 

Mr.  Borthwick 
Mr  Fox  . 

Dr.  Monro 

Dr.  Peacock 

Dr.  Paul  . 

Dr.  King  . 

Dr.  Orr  . 

IVir.  Craven 

Dr.  Manford 
Dr.  Durrant 
Jir.  Haig  . 

]\Ir.  Cadge 

Mr.  Paget 

Dr.  Bainhrigge 
l^Ir.  Morris 

Mr.  Benson 

Dr.  M‘Farlane 
Mr.  Parson 

Mr.  Young 

Mr.  Rayner 

Mr.  Jackson 
Mr.  Sheppard 
Mr.  Ilcy  . 

Date  of  the 
Observations. 

1841- 1846 

1844- 1846 

1845- 1846 
1846 

1840-1845 

1845-1846 

1845-1846 

1842- 1846 
1845-1846 
1844-1846 
1840-1845 
1844-1846 

1840- 1844 

1844- 1846 
1846 

1845- 1846 
1845-1846 

1846 

1841- 1846 
1845-1846 
1845-1846 

1846 

1840-1846 

-1847 

1844- 1846 

1845- 1846 
1845-1846 
1845-1846 

■-1846 

1845-1846 

1 

i 

i 

3 

I 

Aberdeen  Royal  Infirmary 
Bristol,  St.  Peter’s  Hospital  . 
Bristol  Infirmary 

Bristol  General  Hospital  . 

Berks  Royal  Hosidtal 

Cork  Nortliern  Infirmary  . 
Cumberland  Inlirmary 

Dumfries  Infirmary 

Derbysliire  General  Infirmary  . 
Dundee  Infirmary 

Edinburgh  Royal  Infirmary 

Elgin  Infirmary  .... 
Glasgow  Hospital 

Gla.sgow  Hos]>ital 

Hull  General  Infirmary 

Inverness  Infirmary  . 

Ipswich  Infirmary 

London  St.  Bartholomew’s  Hos. 
London  University  College  Hos. 
Leicester  Infirmary  . 

Liverpool  Northern  Hosjiital 
Liverpool  Southern  Hospital 
Newcastle  Infirmary  . 

Perth  Hospital  .... 
Sussex  County  Hospital  . 
Salisbury  Infirmary  . 

Stockport  Infirmary  . 

Siieffield  Infirmary 

Worcester  Infirmary  . 

York  County  Hospital 

Totat. 

C 1 

102 


DEFENCES  OF  ANAESTHESIA. 


The  data  in  the  preceding  Table,  No.  Y.  (p.  101),  when  condensed 
into  the  tabular  form,  afford  the  results  in  the  following  Table, 
No.  VI.— 

No.  VI. — Table  of  the  Mortality  of  618  Amputations  of  the  Thigh, 
Leg,  and  Arm,  without  Anaesthesia,  performed  during  the  last 
few  years  in  30  British  Hospitals. 


Scat  of 
Amputation. 

Primary. 

Secondary, 

No.  of 
Cases. 

No.  of 
Deaths. 

Percentage 
of  Deaths. 

No.  of 
Cases. 

No.  of 
Deaths. 

Percentage 
of  Deaths. 

Thigh  . . . 

73 

45 

63 

211 

62 

29 

Leg  . . . 

80 

26 

32 

135 

23 

17 

Arm  . . 

77 

17 

22 

42 

10 

24 

Total  . . 

230 

88 

. 38 

388 

96 

24 

GENERAL  MORTALITY  OF  AMPUTATIONS  OF  THE  THIGH,  LEG,  AND  ARM, 
UPON  PATIENTS  IN  AN  ANaESTHETIC  STATE. 

In  the  preceding  lengthened  Table,  No.  I.  (pp.  96,  97),  I have 
given  from  forty-nine  different  hospitals  the  detailed  reports  of  302 
amputations  of  the  thigh,  leg,  and  arm.  When  these  302  amputations 
are  reduced  into  a tabular  form,  similar  to  those  which  I have  used 
for  stating  the  data  of  similar  amputations  without  amesthesia,  they 
present  the  following  results  : — 


No.  VII. — Table  of  the  Mortality  of  302  Amputations  of  the  Thigh, 
Leg,  and  Arm,  under  Anaesthesia. 


Seat  of 
Ainiiutation. 

Primary.  j 

Secondary. 

No.  of 
Cases. 

No.  of 
Deaths. 

Percentage 
of  Deaths. 

No.  of 
Cases. 

No.  of 
Deaths. 

Percentage 
of  Deaths. 

Thigh  . . . 

24 

12 

50 

121 

25 

20 

Leg  . . . 

32 

9 

28 

81 

13 

16 

Ann  . . . 

17 

4 

23 

27 

8 

29 

Total  . . 

1 

73 

25 

34 

229 

46 

20 

I shall  now  proceed  to  contrast  these  results  with  the  results  of 
the  same  operations  in  the  same  class  of  hospitals,  and  when  per- 
formed upon  patients  not  in  an  amesthetic  state. 

Before  doing  so,  however,  let  me  observe  in  passing,  that  the 
data  I have  adduced  in  Tables  Nos.  I.  and  V.  (pp.  96-97,  101)  have 


COMPARATIVE  STATISTICS. 


103 


been  objected  to  on  tlie  ground  that  they  are  collected  from  too  many 
different  hospitals,  and  too  many  different  sources.  But,  on  the  con- 
trary, I believe  all  our  highest  statistical  authorities  will  hold  that 
this  very  circumstance  renders  them  more,  instead  of  less,  trust- 
worthy. Professor  Chomel  of  Paris,  after  pointing  out  the  first 
requisite  for  a successful  statistical  comparison  of  therapeutic  or 
other  results — viz.  a sufficient  similarity  between  the  number  of 
collated  cases — adds,  as  the  second  condition,  “ that  the  data  be 
numerous,  collected  at  different  times,  in  different  places,  and,  if 
possible,  by  several  observers.  It  is  easily  seen,”  he  adds,  “ that  the 
results  of  a number  of  facts  too  limited,  collected  in  a short  space  of 
time,  in  a single  place,  and  by  a single  observer,  however  exact  as 
regards  that  individual  series  of  data,  may  yet  be  very  different 
from,  or  even  the  reverse  of,  conclusions  drawm  from  a larger  series, 
and  one  collected  under  various  circumstances.”  ^ 

COMPARISON  OF  THE  MORTALITY  FOLLOAVING  THE  LARGER  AMPU- 
TATIONS OF  THE  LIMBS  — 1.  WITHOUT,  AND  2.  AVITH  ANiES- 
THESIA. 

The  major  amputations  of  the  limbs,  including  those  of  the 
thigh,  leg,  and  arm,  are  generally  fatal  in  hospital  practice  in  the 
proportion  of  about  1 in  every  2 or  3 operated  upon.  In  the  Parisian 
hospitals,  the  fatality,  according  to  Malgaigne,  amounts  to  upwards 
of  I in  2.  In  GlasgOAV,  it  is  2|.  In  British  hospitals,  I found  that 
under  these  amputations  1 in  died.  The  same  operations,  per- 
formed in  the  same  hospitals,  and  upon  the  same  class  of  patients,  in 
an  anaesthetic  state,  present  a mortality  of  23  in  100,  or  1 in  4 only. 
The  following  Table  shows  the  amount  of  the  indi\ddual  cases,  and 
the  percentage  of  deaths  in  different  collections,  Avith  the  corre- 
sponding proportion  of  deaths  in  those  operated  on  in  an  anaesthetic 
state. 


No.  VIII. — Table  of  the  Mortality  of  Amputation  of  the 
Thigh,  Leg,  and  Arm. 


Reporter 

No.  of 
Cases. 

No.  of 
Deatlis. 

Percentage 
of  Deaths. 

Parisian  Hospitals — Malgaigne 

484 

273 

57  in  100 

Glasgow  Hospital — Lawrie  . . 

242 

97 

40  in  100 

General  Collection — Phillips  . . 

1369 

487 

35  in  100 

British  Hospitals— Simpson  . . 

Upon  Patients  in  an  Etherised 

618 

183 

29  in  100 

State  

302 

71 

23  in  100 

^ Bulletin  de  V Acad.  Boy.  de  Medccine.  Seance  du  Mai  2,  1837- 
63 


104 


DEFENCES  OF  ANAESTHESIA. 


The  evidence  which  the  preceding  table  affords  in  favour  of  the 
greater  safety  of  amputation  with  anaesthesia  than  without  it,  is 
sufficiently  strong  and  striking.  While  23  in  100  died  under  the 
amputations  named,  when  the  operations  were  performed  upon 
patients  in  an  anaesthetic  state,  29  in  every  100  died  under  the 
same  amputations  in  the  same  hospitals  when  the  patients  were  not 
anaesthetised  ; — in  the  Glasgow  hospital  as  many  as  40  in  100  died  ; 
and  in  Paris,  as  many  as  57  per  cent.  In  other  words,  out  of  every 
100  persons  submitted  to  amputations  of  the  thigh,  leg,  or  arm,  the 
lives  of  six  were,  by  the  employment  of  anaesthesia,  saved  above  the 
average  number  of  the  same  operations  in  British  hospitals; — 17 
lives  in  each  100  were  saved,  if  we  take  the  Glasgow  returns  as  a 
standard  of  comparison  ; the  average  mortality  was,  under  anaes-  . 
thesia,  less  by  34  in  every  100  cases  than  that  which  was  found 
by  Malgaigne  to  accompany  the  same  operations  in  the  Parisian 
hospitals. 

But  probably,  to  most  minds,  this  comparison  would  be  rendered 
more  clear  and  simple,  if  we  took  not  a class  of  operations,  but  a 
single  operation  as  a standard  and  medium  of  comparison.  For  this 
purpose  let  us  select  amputation  of  the  thigh  as  the  individual 
operation  regarding  which  we  possess  the  largest  series  of  observa- 
tions.^ 

COMPARISON  OF  THE  MORTALITY  FOLLOWING  AMPUTATIONS  OF 
THE  THIGH — 1.  WITHOUT,  AND  2.  WITH  ANaESTHESIA. 

There  are  few  or  none  of  the  operations  deemed  justifiable  in 
surgery,  that  are  more  fearfully  fatal  in  their  results  than  amputa- 
tion of  the  thigh.  “ The  stern  evidence,”  says  Mr.  Syme,  “ of  hospi- 

1 One  objection  may  be  urged  against  the  comparison  of  the  results  of  a single 
operation,  with  or  without  anaesthesia,  that  I am  now  about  to  institute,  on  the 
ground,  viz,  that  the  number  of  cases  (145)  is  too  limited  to  afford  a result  that 
is  perfectly  decisive.  1 am  perfectly  willing  to  admit  the  justness  of  this  remark 
in  a statistical  point  of  view,  and  to  hold  this  part  (and  indeed  the  whole  of  the 
present  inquiry)  as,  so  far,  the  commencement  and  nucleus  merely  of  a more  full 
and  lengthened  investigation  by  other  hands.  At  the  same  time  I have,  during 
the  course  of  the  inquiry,  had  the  conviction  impressed  upon  me,  that  future 
results  will  more  and  more  confirm  those  that  I have  here  stated  in  the  text,  and 
be  still  more  in  favour  of  etherisation  ; for  no  small  number  of  the  operations 
reported  to  me  were,  in  the  first  periods  of  the  new  practice,  doubtlessly  performed 
upon  patients  in  whom  the  anaesthesia  was  by  no  means  entire  and  complete,  in 
consequence  of  imperfection  in  the  forms  of  apparatus,  in  their  management,  in 
the  dose  given,  etc.  ; and  I believe  that,  as  the  profession  becomes  more  accom- 
plished and  certain  in  the  use  of  such  measures,  the  resulting  effects  will  become 
proportionally  happier  and  more  favourable. 


COMPARATIVE  STATISTICS. 


105 


tal  statistics  shows,  that  the  average  frequency  of  death  is  not  less 
than  from  60  to  70  per  cent,”  ^ or  above  one  in  every  two  operated 
on  die.  Out  of  987  cases  of  amputation  of  the  thigh  collated  by 
Mr.  Phillips,  435  proved  fatal,  or  44  in  every  100  were  lost.^  “ On 
referring,”  observes  Mr.  Curling,  “to  a table  of  amputations  in  the 
hospitals  of  London,  performed  frotn  1837  to  1843,  collected  with 
care  by  a private  society  to  which  I have  the  honour  of  belonging 
(the  Medical  Society  of  Observations),  I find  134  cases  of  amputa- 
tion of  the  thigh  and  leg,  of  which  55  were  fatal,  giving  a mortality 
of  41  per  cent.”  ^ Out  of  201  amputations  of  the  thigh  performed  in 
the  Parisian  hospitals,  and  reported  by  Malgaigne,  126  ended  fatally. 
In  the  Edinburgh  Infirmary  21  died  out  of  43.  Dr.  Lawrie  found 
the  mortality  attendant  upon  this  operation  in  the  Glasgow  hospital 
to  amount  to  46  deaths  in  127  cases.  In  the  collection  of  cases  from 
thirty  different  British  hospitals,  which  I have  published  in  table 
No.  V.  (p.  101),  284  cases  of  amputation  of  the  thigh  are  reported; 
107  out  of  these  284  operations  proved  fatal.  On  the  contrary,  I 
have  collated  145  cases  in  which  the  same  operation  has  been  per- 
formed during  the  past  year  in  British  hospitals,  upon  patients  in  an 
anaesthetic  state.  Out  of  these  145  cases  of  amputation  of  the 
thigh,  only  37  proved  fatal.  Or,  in  other  words,  the  fatality  was 
not  greater  than  one  in  every  four  operated  on  when  the  patieAts 
were  previously  an^sthetised.  It  was  as  high  as  one  in  every  two 
or  three  operated  upon  when  the  patients  were  not  previously  anaes- 
thetised. The  following  table  presents  these  results  in  a more  clear 
form  : — 


No.  IX. — Table  of  the  Mortality  op  Amputation  op  the  Thigh. 


Name  of  Reporter. 

No.  of 
Cases. 

No.  of 
Deaths. 

Percentage  of 
Deaths. 

Parisian  Hospitals — Malgaigne  . . 

201 

126 

62  in  100 

Edinburgh  Hospital — Peacock  . . 

43 

21 

49  in  100 

General  Collection — Phillips  . . . 

987 

435 

44  in  100 

Glasgow  Hospital — Lawrie  . . . 

127 

46 

36  in  100 

British  Hospitals — Simpson  . . . 

284 

107 

38  in  100 

Upon  Patients  in  an  Anaesthetised 
Slate 

145 

37 

25  in  100 

The  preceding  figures  speak  in  a language  much  more  emphatic 

^ Monthly  Journal  for  May  1845,  p.  337. 

- Medical  Gazette  for  1844,  p.  805. 

® Address  to  tlie  Hunterian  Society  of  London,  1848,  p.  31. 


106 


DEFENCES  OF  ANAESTHESIA. 


than  any  mere  words  that  I could  employ  in  favour  of  ansesthesia, 
not  only  as  a means  of  preserving  surgical  patients  from  pain,  but 
as  a means  also  of  preserving  them  from  death.  Between  even  the 
lowest  mortality  in  the  table  without  anaesthesia,  36  in  100,  and 
the  rate  of  mortality  with  it,  25  in  100,  there  is  the  difference  of  11 
per  cent.  That  is  to  say,  according  to  this  standard,  out  of  every 
100  patients  submitted  to  amputation  of  the  thigh  without 
anaesthesia,  1 1 more  would  die  from  the  operation  than  if  the  same 
100  patients  were  submitted  to  the  same  operation  in  a state  of 
anaesthesia.  And  if  the  condition  of  anaesthesia  effects  thus  a 
saving  of  11  lives  in  every  100  amputations  of  the  thigh,  then  out 
of  every  1000  such  operations  the  lives  of  110  patients  would  be 
preserved  by  the  use  of  antipathic  means. 

If  we  compare  these  results  with  the  standard  of  Mr.  Phillips, 
the  contrast  is  still  more  startling.  Out  of  987  amputations  of  the 
thigh  collected  by  him,  435  proved  fatal,  or  44  in  the  100.  Out  of 
145  amputations  of  the  thigh  under  anaesthesia,  37  proved  fatal,  or 
25  in  100.  According  to  this  comparison,  the  number  of  persons 
saved  from  death  in  amputation  of  the  thigh  by  the  patients  being 
rendered  anaesthetic  during  the  operation,  amounts  to  19  lives  in 
every  100  operations  performed. 

* In  conclusion,  led  me  add,  that  when  anaesthesia  first  began  to 
be  employed  in  surgical  operations,  it  was  eagerly  argued  that  its 
adoption  produced  a greater  tendency  to  primary  and  secondary 
hemorrhage,  to  imperfect  union  of  the  wounds,  to  pneumonia,  etc. 
If  my  space  had  permitted,  it  was  mj-  intention  to  show,  from  the 
analyses  of  the  three  hundred  cases  of  amputation  reported  to  me, 
that  these  various  allegations  were  foundationless  and  imaginary* — 
that  such  consequences  were  not  so  frequent  after  amputations  with 
ainesthesia  as  after  amputations  previously  performed  without  it — 
that  as  the  casualties  were  reduced  in  number,  so  were  also  the 
attendant  accidents  and  complications.^  But  I believe  such  proof 
to  be  at  the  present  day  superfluous,  as  few  or  none  now  maintain 
such  opinions.  AVhen  writing  to  me  as  early  as  in  June  last  on 
this  subject,  the  late  lamented  Mr.  Liston  stated  what  all  the  subse- 
quent experience  of  our  ablest  surgeons  here  and  in  London  has 

^ Some  of  my  correspondents,  who  expressed  the  strongest  opinions  in  regard 
to  the  reality  of  these  supposed  evil  consequences,  have,  I know,  now  abandoned 
such  opinions  as  utterly  untenable. 

2 In  my  communication  to  the  Medico-Chirurgical  Society  in  June  last,  I 
w'cnt  over  this  ground  at  some  length. 


COMPARATIVE  STATISTICS. 


107 


confirmed.  “ The  ether,”  says  he,  “ produces  no  bad  effect,  as  far  as 
I can  see.  There  is  no  change  in  the  blood,  nor  in  the  vessels  or 
muscles.  The  recoveries  are,  at  least,  quite  as  good  as  before  it  was 
employed.”  An  excellent  surgical  pathologist  (Mr.  Curling,  surgeon 
to  the  London  Hospital)’  has  more  recently  afforded  still  stronger 
testimony  to  the  same  effect.  “ I have  carefully  watched,”  says  he, 
“ the  progress  of  cases,  after  operations  of  various  kinds  performed 
upon  patients  in  a state  of  anaesthesia,  and  I can  with  confidence 
declare  that,  so  far  as  my  present  experience  has  reached,  the  con- 
stitutional symptoms  have  been  milder,  and  the  cases  have  pro- 
ceeded more  satisfactorily,  than  after  operations  in  which  no  means 
had  been  taken  to  prevent  pain.  Several  of  my  surgical  friends 
can  fully  confirm  this  statement.” 

I have  also  avoided  entering  into  the  theoretical  question — How 
does  ansesthesia  render  severe  operations  less  fatal  and  dangerous  in 
their  consequences  1 I have  already  shown ^ that  the  endurance  of 
severe  pain  is  in  itself  depressing  and  destructive  ; and  apparently 
the  anaesthetic  state  saves  the  patient  from  this  suffering  and  its 
effects,  as  well  as  saves  him,  in  some  degree,  from  the  shock  of  the 
operation  and  its  consequences.  When  writing,  in  1839,  on.  the 
subject  of  pain  and  shock,  and  on  certain  states  connected  with  or 
produced  by  wounds  or  injuries.  Professor  Burns  of  Glasgow  offered 
some  remarks  bearing  directly  on  the  present  subject,  and  which  are 
more  valuable -as  they  were  written  without  any  theory,  and  without 
any  prospect  of  such  a state  as  he  speaks  of  being  capable  of  being 
artificially  induced.  I shall  quote  them  in  his  own  words  : — “ The 
mere  lopping  off  of  the  member  by  the  abridgment  of  the  quantity  of 
living  body,  the  instant  loss  of  so  large  a portion  which  v/as  for- 
merly acting  along  with  the  system,  is  productive  of  serious  evil  to  it 
from  the  sympathy  which  universally  prevails.  But  if  the  nervous 
system  becomes  in  part  torpid,  so  as  to  prevent  this  sympathy,  or  to  be 
incapable  of  maintaining  it,  the  loss  of  a member,  or  wdiat  is,  in 
one  respect,  the  same,  the  loss  of  its  connection  with  the  system, 
and  its  failure  in  power  and  action  and  sensibility,  may  not  have  tlie 
same  bad  effect.” 

^ Address  to  the  Hunterian  Society  of  London,  1848,  p.  23. 

2 See  ante,  p.  83,  etc. 

* Principles  of  Surgery,  vol.  i.  p.  493. 


108 


DEFENCES  OF  ANAESTHESIA 


CHAPTER  VIL 

ANSWER  TO  OBJECTIONS  TO  ANAESTHESIA  IN  MIDWIFERY. 

Edinburgh,  October  1848. 

Objections  of  various  kinds,  religious,  moral,  and  medical,  have 
been  • zealously  brought  against  the  practice  of  anaesthesia  in  mid- 
wifery. 

I have  already  attempted^  to  answer  the  supposed  religious 
objections  that  were  at  first  so  very  strongly  urged  in  various 
quarters  against  the  practice,  on  the  supposed  ground  of  the  per- 
manence of  the  primeval  curse  ; and  I have  shown  that  the  disputed 
word  “ sorrow,”  'etzebh  (“  in  sorrow  thou  shalt  bring  forth  children  ”), 
does  not  in  the  original  Hebrew  really  signify  the  sensations  of  pain, 
but  the  muscular  efforts  and  contractions  connected  with  childbirth. 
Besides,  if  this  were  not  the  fact,  and  it  was  the  duty  of  man 
to  give  effect  to  the  curse,  instead  of  struggling  to  ameliorate  and 
resist  its  penalties  and  influences,  then  the  whole  art  of  physic  would 
require  to  be  abandoned  entirely,  for,  in  the  primeval  curse,  man 
was  doomed  to  die  ; and  yet  is  not  the  great  leading  aim  and  object 
of  the  physician  a continuous  attempt  to  preserve  him  in  life  1 All 
forms  of  obstetric  assistance  would  require  also  to  be  rejected,  for 
the  whole  art  and  science  of  midwifery  is  one  undivided  effort  to 
abate  and  ameliorate  the  effects  of  the  curse  ; and  to  attain  that 
object  imperfectly,  as  heretofore,  by  venesection,  baths,  by  counter- 
pressure to  the  back,  and  other  minor  practices,  is  as  sinful  as  to 
attain  it  more  perfectly  now  by  anaesthetics,  inasmuch  as  the  prin- 
ciple of  interference  is  not  altered  by  the  degree  of  relief  given  ; 
“ for  whosoever  shall  keep  the  whole  law,  and  yet  offend  in  one  point, 
he  is  guilty  of  all.”  In  short,  if  there  is  any  evidence  of  feelings  of 
impiety  and  irreligion  in  the  whole  question,  it  is  surely  on  the  side 
of  those  persons  who  suppose  that  pain  is  permanently  ordained  in 
the  primal  curse  as  an  accompaniment  of  human  parturition ; and 

1 See  ante,  Part  II.  Chaps,  i.  and  ii. ; see  also  a pamphlet  by  Dr.  Protheroe 
Smith,  entitled,  Scriptural  Authority  for  the  Mitigation  of  the  Pains  of  Labour. 


IN  MIDWIFEEY. 


109 


yet  that  by  aiifesthetics,  man,  the  creature,  has  discovered  a power 
by  which  he  can  alter  and  subvert  an  immutable  decree  of  God,  the 
Creator. 

The  principal  moral  “ objection,”  as  it  has  been  termed,  against 
the  employment  of  ana3sthesia  in  midwifery,  amounts  to  the  often- 
repeated  allegation,  that  it  is  “unnatural.”  “Parturition,”  it  is 
avowed,  is  a “ natural  function,”  the  pain  attendant  upon  it  is  a 
“ physiological  pain  ” — (Dr.  Meigs) ; ^ and  it  is  argued  that  it  is 
impossible  “ to  intermeddle  with  a natural  function ;”  and  to  use 
anaesthetics  is  a piece  of  “ unnecessary  interference  with  the  pro- 
videntially arranged  process  of  healthy  labour” — (Dr.  Ashwell'). 
The  above  is,  perhaps,  the  most  general  and  approved  of  all  the 
objections  entertained  and  urged  at  this  moment  against  the  practice 
of  anaesthesia  in  midwifery.  But  it  certainly  is  a very  untenable 
objection ; for,  if  it  were  urged  against  any  of  our  similar  inter- 
ferences with  the  other  physiological  functions  of  the  body,  every 
one  of  which  is  as  “ providentially  arranged  ” as  the  function  of 
parturition,  then  the  present  state  of  society  would  require  to  be 
altogether  changed  and  revolutionised.  For  the  fact  is,  that  almost 
all  the  habits  and  practices  of  civilised  life  are  as  “ unnatural,”  and 
as  direct  interferences  with  our  various  “ providentially  arranged  ” 
functions,  as  the  exhibition  of  anaesthetics  during  labour.  Progres- 
sion upon  our  own  two  lower  extremities  is  a “ providentially 
arranged  ” function,  a “ natural  process  ; ” and  yet  we  “ unnaturally  ” 
supplement  and  assist  it  by  constantly  riding  on  horseback  and  in 
carriages,  etc.  The  “ physiological  process  ” of  walking  is  apt  to 
produce  pain  and  injury  of  the  uncovered  foot  of  man,  and  we 
“ unnaturally  ” use  boots  and  shoes  to  bind  the  foot,  and  add  to  the 
protecting  power  of  the  cutaneous  and  other  structures  of  the  sole. 
Mastication  and  digestion  are  “ natural  processes  ;”  but  we  daily 
intermeddle  with  and  attempt  to  aid  them  by  the  arts  of  cookery 
and  dietetics ; and  so  on  with  regard  to  other  functions. 

To  annul  the  pain  of  labour  by  anpesthetics,  is,  argues  Dr. 
Meigs,  “ a questional)le  attempt  to  abrogate  one  of  the  general  con- 
ditions of  man.”  Biding  and  railway  travelling  abrogate  one  of  the 
general  conditions  of  man  (progression),  and  are  constantly  leading 
to  accidents  and  deatlis.  Should  we  never  travel  therefore  except 
on  foot  ? Disease  and  death  itself  form  one  of  the  m^ost  “ general 

^ Philadelphia  Medical  Examiner,  March  1848,  p.  152. 

2 Lancet  for  March  11,  1848,  p.  291. 


110 


DEFENCES  OF  ANAESTHESIA 


conditions  of  man,” — and  medicine  is  a “ questionable  attempt  to  ab- 
rogate  them.”  Should  medicine  therefore  be  abandoned  'i 

In  a note  now  lying  before  me,  an  eminent  London  divine  urges 
the  following  objections  against  anaesthesia,  either  in  midwifery  or 
surgery  ; and  I notice  it  here,  because  it  is  an  objection  which  I have 
often  heard  repeated.  He  writes  : — “ The  question  with  me  is  not 
the  alleviation  of  pain,  but  the  destruction  of  consciousness.  .1 
should  hesitate  greatly  to  take  a step  which  destroys  consciousness.” 
Now,  certainly,  our  consciousness  is  destroyed  in  natural  sleep  as 
much  as  in  the  anaesthetic  sleep.  T have  little  doubt  that  the  dis- 
tinguished writer  whom  I have  quoted,  has,  many  a day,  perhaps 
during  almost  every  day  for  a long  lifetime,  voluntarily  given  up  and 
destroyed  his  own  consciousness  in  sleep,  for  an  hour  or  two  longer 
each  morning  than  the  necessities  of  his  system  required.  Putting 
these  many  hours  together,  he  has,  perhaps  now,  from  first  to  last, 
unnecessarily,  but  voluntarily,  surrendered  up  his  mental  conscious- 
ness for  periods,  that,  if  added  together,  would  count  up  weeks,  and 
months,  and  perhaps  years.  He  has  done  so  too,  merely  for  the 
reprehensible  indulgence  of  indolence ; and  yet  he  insists  upon  his 
fellow-creatures  not  surrendering  up  their  consciousness  for  a short 
time,  on  rare  and  extraordinary  occasions,  when  the  object  is  the  far 
more  legitimate  one  of  the  avoidance  of  unnecessary  physical  pains, 
and  the  securing  life  and  health  by  saving  the  system  from  the 
endurance  of  these  pains.  If  we  may  sleep,  and  thus  indulge  in  the 
destruction  of  consciousness  to  avoid  and  cure  corporeal  fatigue, 
surely  we  may  do  the  same  to  avoid  and  cure  corporeal  agony. 

Dr.  Merriman  ^ opposes  the  employment  of  anaesthesia  in  natural 
labour,  on  the  ground  of  “ the  great  superiority  of  allowing  nature 
to  conduct  the  whole  process  of  the  birth.”  But  tlie  practice  of 
anassthesia  does,  in  reality,  allow  “nature  to  conduct  the  whole 
process  of  the  birth  it  merely  abstracts  that  intensity  of  pain  and 
suffering  which  accompanies  the  act  of  labour  in  the  civilised  woman 
— a “disadvantage  inseparable”  from  civilisation,  to  employ  Dr. 
Merriman’s  own  expression,  and  which  is  not  an  essential  part  of 
the  process  of  parturition,  according  to  his  own  doctrine ; for,  as  he 
himself  states,  “in  the  earliest  ages  of  the  world,  and  in  savage 
nations  at  present,  childbirth  appears  to  have  been,  in  almost  every 
instance,  easily  accomplished ; the  mother  suffers  little^  And  in 
this  state  of  natural  anresthesia,  the  convalescence  of  the  mother  is 

^ Arguments  against  the  Indiscriminate  Employment  of  Anaesthetic  Agents  in 
Midicifcry.  London,  1848. 


IN  MIDWIFERY. 


Ill 


consequently  unusually  rapid ; for,  again  to  quote  Dr.  Merriman’s 
vrords,  she  almost  “ at  once  resumes  her  ordinary  occupations.”  Dr. 
Merriman  afterwards,  in  speaking  of  the  use  of  chloroform,  decries 
its  propriety  in  any  except  “ instrumental  or  very  tedious  labours,” — 
arguing  that  w'e  should  not  interfere  unless  where  the  labour  is 
morbid,  for  (to  use  his  own  words),  “ the  duty  of  the  physician  is  to 
imitate  nature  as  far  as  possible,  and  watch  her  methods  of  acting.” 
But  surely  the  physician  strictly  imitates  nature  in  her  most  natural 
state,  according  to  Dr.  Merriman’s  own  premises,  when,  during 
labour,  he  induces  by  art  that  state  of  anaesthesia,  which,  in  Dr. 
Merriman’s  opinion,  originally  pertains  to  parturition  in  the  human 
mother.  The  female  in  an  uncivilised  state  more  truly  shows  us  the 
true  method  and  types  of  nature,  than  the  female  in  a civilised 
state.  Besides,  are  we  not  called  upon  to  relieve  the  woman,  when 
we  can,  of  her  sufferings,  as  an  act  of  common  professional  duty  and 
common  professional  humanity  ? In  law  and  in  morals,  we  judge 
greatly  of  actions  by  their  intent.  No  accoucheur  would  intention- 
ally inflict  upon  a patient  the  agonies  of  labour  by  a deliberate  act 
of  commission  on  his  part.  Is  an  accoucheur  properly  justified  in 
intentionally  refusing  to  save  a patient  from  the  agonies  of  labour, 
by  a deliberate  act  of  omission  on  his  part  1 When  a child,  at  birth, 
is  intentionally  destroyed  by  the  loss  of  blood,  it  does  not  matter,  in 
the  eye  of  the  law,  whether  the  death  has  been  produced  by  volun- 
tarily omitting  to  tie  the  umbilical  vessels,  or  voluntarily  opening 
other  vessels. 

Up  to  within  the  last  few  months,  and  till  the  power  of  an- 
nulling pain  by  the  inhalation  of  ether  was  discovered,  severe  bodily 
pain,  such  as  we  witness  in  surgery  and  midwifery,  was  universally 
regarded  by  the  profession  as  possessing  an  evil  and  morbid  effect. 
Some  of  the  opponents  of  anjesthesia  have  taken  up  a novel  and 
different  view  ; and,  as  a medical  argument  against  the  practice  of 
anaesthesia  in  midwifery,  it  has  been  particularly  averred  that  a 
labour  pain  is  a “ desirable,  salutary,  and  conservative  manifestation 
of  life  force” — (Dr.  Meigs).  Parturient  “ pain  is,”  says  Dr.  Coq)land,^ 
“ often  salutary  as  respects  its  effects ; neither  its  violence  nor  its 
continuance  is  productive  of  injury  to  the  constitution,”  etc.  No 
opinion,  I believe,  could  be  more  erroneous.  I have  already  shown, 
from  the  evidence  of  extensive  statistical  returns,  that  some  of  the 
graver  operations  of  surgery  are  now  much  less  fatal  in  their  results 
when  patients  are  operated  on  under  the  condition  of  ansesthesia, 
^ Dictionary  of  Practical  Mcclicine,  vol.  iii.  p.  484. 


112 


DEFENCES  OF  ANESTHESIA 


and  consequently  without  any  attendant  pain,  than  the  same  opera- 
tions  were  formerly,  when  patients  were  submitted  to  all  the  agonies 
of  the  surgeon’s  knife  in  their  usual  waking  and  sensitive  state.  The 
prevention  of  the  pain  in  surgical  operations  is,  in  other  words,  one 
means  of  preventing  danger  and  death  to  those  operated  on ; the 
saving  of  human  suffering  implies  the  saving  of  human  life.  And 
what  holds  good  in  relation  to  pain  in  surgery,  holds  good  in  relation 
to  midwifery.*  Pain,  whenever  it  is  great  in  degree  or  great  in 

^ Custom  and  prejudice,  and,  perhaps,  the  idea  of  its  inevitable  necessity, 
make  both  the  profession  and  our  patients  look  upon  the  amount  and  intensity  of 
pain  encountered  in  common  cases  of  natural  labour,  as  far  less  worthy  of  con- 
sideration than  in  reality  it  is.  Viewed  apart,  and  in  an  isolated  light,  the  degree 
of  actual  pain  usually  endured  during  common  labour  is  as  great,  if  not  greater, 
than  that  attendant  upon  most  surgical  operations.  I allude  particularly  to  the 
excessive  pain  and  anguish,  which  in  nine  out  of  ten  cases  accompany  the  passage 
of  the  child’s  head  through  the  outlet  of  the  pelvis  and  external  parts.  Speaking 
of  common  or  natural  labour  in  its  last  stages.  Dr.  Merriman  observes,  the  pulse 
gradually  ‘ ‘ increases  in  quickness  and  force  ; the  skin  grows  hot ; the  face  becomes 
intensely  red  ; drops  of  sweat  stand  upon  the  forehead  ; and  a perspiration,  some- 
times profuse,  breaks  out  all  over  the  body  ; frequently  violent  tremblings  accom- 
pany the  last  pain,  and  at  the  moment  that  the  head  passes  into  the  world,  the 
extremity  of  suffering  seems  to  be  beyond  endurance.” — {Synopsis  of  Parturition, 
p.  15.)  Or,  take  the  picture  of  the  suffering  of  the  mother  in  the  last  stage  of 
natural  labour,  as  portrayed  by  the  most  faithful  of  living  observers — Professor 
Naegele  of  Heidelberg. — “The  pains,”  he  observes,  “of  this  stage  are  still  more 
severe,  painful,  and  enduring  ; return  after  a short  interval,  and  take  a far  gi'eater 
effect  upon  the  patient,  than  those  of  the  previous  stage.  Their  severity  increases 
so  much  the  more  from  the  additional  suffering  arising  from  the  continxially 
increasing  distension  of  the  external  parts.  They  convulse  the  whole  frame,  and 
have  hence  been  called  the  dolorcs  conqiiassantes.  The  bearing  down  becomes 
more  continued,  and  there  is  not  unfrequently  vomiting.  The  patient  quivers  and 
trembles  all  over.  Her  face  is  flushed,  and,  with  the  rest  of  the  body,  is  bathed  in 
perspiration.  Her  looks  are  staring  and  wild  ; her  features  alter  so  much  that 
they  can  scarcely  be  recognised.  Her  impatience  rises  to  its  maximum  with  loud 
crying  and  w^ailing,  and  frequently  expressions  which,  even  with  sensible,  high- 
principled  women,  border  close  upon  insanity.  Everything  denotes  the  violent 
manner  in  which  both  body  and  mind  are  affected.” — {Lehrhuch  der  Gchurtshiilfe, 
p.  104.  See  Brit,  and  For.  Medical  Review,  vol.  xix.  p.  64.) 

I have  stated  that  the  question  which  I have  been  repeatedly  asked  is  this — 
Shall  we  ever  be  “justified  ” in  using  the  vapour  of  ether  to  assuage  the  pains  of 
natural  labour  ? Now’,  if  experience  betimes  goes  fully  to  prove  to  us  the  safety 
with  which  anaesthesia  may,  under  proper  precautions  and  management,  be 
employed  in  the  course  of  parturition,  tlien,  looking  to  the  facts  of  the  case,  and 
considering  the  actual  amount  of  pain  usually  endured  as  shown  in  the  descrip- 
tions of  Merriman,  Naegele,  and  others — Dr.  Rigby,  in  his  System  of  Midwifery, 
p.  103,  observes,  “This  is  the  moment  of  greatest  pain,  and  the  patient  is  quite 
wild  and  frantic  with  suffering  ; it  approaches  to  a species  of  insanity,”  etc.  etc. — 

I believe  that  the  question  will  require  to  be  quite  changed  in  its  character.  For, 
instead  of  determining  in  relation  to  it  whether  we  shall  be  “justified”  in  using 


IN  MIDWIFERY. 


113 


duration,  is  in  itself  deleterious ; and  by  shielding  our  patients,  by 
anaesthetic  measures,  against  the  more  severe  portion  of  the  pains  of 
parturition,  we  not  only  preserve  them  from  the  agony  of  their  more 
immediate  sufferings,  but  we  preserve  their  constitutions  also  from 
the  effects  and  consequences  of  these  sufferings.  And  the  evidence ' 
which  I have  adduced  in  the  preceding  pages  tends  to  prove,  that 
when  thus  freed  from  the  endurance  of  pain  by  artificial  anaesthesia, 
they  assuredly,  as  a general  rule,  make  both  more  rapid  and  more 
perfect  recoveries  than  when  such  means  are  not  used ; just  as 
woman  in  a savage  state,  and  where  she  enjoys  a kind  of  natural 
anaesthesia  during  labour,  recovers  more  easily  and  rapidly  from  the 
shock  of  labour  than  the  civilised  female.  In  short,  in  cancelling 
the  pains  of  parturition  by  anaesthesia,  we  also,  I believe,  to  a great 
extent,  cancel  the  perils  of  the  process ; for  the  mortality  accom- 
panying labour  is  regulated  principally  by  the  previous  length  and 
degree  of  the  patient’s  sufferings  and  struggles.  In  the  Dublin 
Lying-in  Hospital,  when  under  Dr.  Collins’s  able  care,  out  of  all  the 
women,  7050  in  number,  who  were  delivered  within  a period  of  two 
hours  from  the  commencement  of  labour,  22  died  ; or  1 in  every  320. 
In  452  of  his  cases,  the  labour  was  prolonged  above  twenty  hours; 
and  of  these  452,  42  died;  or  1 in  every  11 — a difference  enormous 
in  its  amount,  and  one  surely  calculated  to  force  us  all  to  think 
seriously  and  dispassionately  of  the  effects  of  severe  suffering  upon 
the  maternal  constitution. 

The  last,  and  certainly  the  principal  objection  against  anaesthesia 
in  midwifery,  is  the  supposed  danger  accompanying  the  exhibition 
of  anaesthetic  agents.  In  the  earliest  paper  which  I pviblished  on 
the  subject  of  chloroform,  I pointed  out  this  circumstance  in  men- 
tioning various  cautions  in  the  use  of  it.  When  we  consider  the 
immense  extent  to  which  it  has  already  been  employed  in  all  quarters 
of  the  world,  in  medicine,  surgery,  and  midwifery — the  little  care 

this  agent  under  the  circumstances  named,  it  Avill  become,  on  the  ether  hand, 
necessary  to  determine  whether  on  any  grounds,  moral  or  medical,  a profes- 
sional man  could  deem  himself  “justified”  in  withholding,  and  not  using  any 
such  safe  means,  as  we  at  present  presuppose  this  to  be,  provided  he  had  the 
power  by  it  of  assuaging  the  pangs  and  anguish  of  the  last  stage  of  natural 
labour,  and  thus  counteracting  what  Velpeau  describes  as  “those  piercing 
cries,  that  agitation  so  lively,  those  excessive  efforts,  those  inexpressible  agonies, 
and  those  pains  apparently  intolerable”  {Traite  des  Accouclicmens,  vol.  i.  p. 
449),  which  accompany  the  termination  of  natural  parturition  in  the  human 
mother. 


114 


DEFENCES  OF  ANESTHESIA 


sometimes  observed  in  its  use — and  the  deleterious  and  dangerous 
articles  with  which  it  is  sometimes  mixed,  the  wonder  is  that 
so  few  alleged  accidents  have  happened  from  its  employment. 
Ey  saving  a vast  amount  of  human  suffering,  it  has  already,  I 
believe,  been  the  means  of  saving  no  small  amount  of  human 
life ; and  it  is  assuredly  improper  to  argue,  as  some  have  done, 
that  the  mere  chance  of  its  disagreeing  with  some  rare  and 
special  constitution,  now  and  then,  is  any  valid  reason  for  refusing 
its  use  for  the  abatement  and  abrogation  of  human  suffering.  If 
there  w^ere  any  soundness  in  the  reasoning,  a thousand  things  beside 
would  require  to  be  abandoned.  Eailways,  steamboats,  stage- 
coaches, etc.,  when  used  as  substitutes  for  the  natural  and  physio- 
logical function  of  human  progression,  are  ever  and  anon  attended 
with  accidents  to  limb  and  life.  But  surely  no  one  would,  from 
this,  maintain  that  these  means  of  conveyance  should,  in  conse- 
quence, be  abandoned.  Many  persons  are  annually  droAvned  in 
bathing — Should  bathing,  therefore,  be  prohibited,  and  this  power- 
ful means  of  maintaining  and  restoring  health  be  entirely  forsaken  ? 
According  to  the  Registrar’s  official  returns,  a great  number  of  lives ^ 
are  lost  yearly  in  England  by  the  improper  medical  use  of  opium — 
Should  the  use  of  opium,  therefore,  be  given  up  ? Patients  some- 
times sink  under  the  depressing  action  of  antimony,  calomel,  etc. — 
Should  these  valuable  drugs,  therefore,  be  banished  from  the  Phar- 
macopoeia ? Many  a patient  has  perished  in  consequence  of  vene- 
section— Should  this  operation  be  expunged  from  the  art  of  surgery] 
From  mistakes  and  errors,  etc.,  in  diagnosis  and  practice,  medicine 
and  surgery  are  sometimes  the  unhappy  means  of  destroying  instead 
of  saving  life — Should  these  arts,  consequently,  be  interdicted  ] 
Works  on  medical  subjects  have  sometimes  led  both  patients  and 
practitioners  into  serious  and  fatal  "errors — Should  no  medical 
works,  therefore,  be  allowed  to  be  printed  ] Long  ago  Raynalde, 
in  sending  forth  the  FIRST  w^ork  on  midwifery  ever  published  in 
the  English  language,  seems  to  have  foreseen  that,  against  the  utility 
of  publishing  any  book  or  books  on  midwifery,  the  same  argument 
would  be  used  as  Ave  have  found  in  our  OAvn  day  used  against  the 

^ In  1840,  out  of  every  1,000,000  living  in  England  and  Wales,  24  Avere  poi- 
soned by  opium,  and  22  by  other  medicines  improperly  given  to  children  below 
the  age  of  five  years  alone. — See  Seventh  Annual  Report,  p,  82.  See  Taylor  on 
Poisons,  p.  187,  etc.,  for  the  gi’cat  numbers  destroyed  in  England  by  opium,  etc., 
improperly  given. 


IN  MIDWIFERY. 


116 


application  of  anaesthesia  to  midwifery ; and  he  has  answered  the 
argument  in  a style  so  earnest  and  apposite,  that  I shall  quote 
this  reply,  by  anticipation  as  it  were,  in  his  own  words,  and  in  an 
abridged  form  : — 

“ Loe  ! — such  is  the  lyght  judgement  of  them,  the  which  in  every 
thyng,  wherof  may  ensue  both  good  and  evyll,  have  alwayes  theyr 
eyes  wakyng  and  firmely  affixed  and  directed  uppon  the  evyll,  pyck- 
yng  and  choosyng  out  the  worst  of  every  matter,  omittyng  and 
leavyng  to  speake  of  the  best,  as  the  thyng  whiche  were  nothyng  to 
theyr  purpose.  If  every  thyng  in  this  worlde  shoulde  be  wayed  and 
passed  uppon  after  this  sort,  then  shoulde  we  be  fayne  to  condempne 
and  banishe  those  thynges  farre  from  us,  whiche  are  at  this  tyme 
accompted  and  taken  for  the  most  necessarie,  worthy,  and  of  greatest 
price  or  estimation.  For  to  be  short,  there  is  nothyng  under  Heaven 
so  good,  but  that  it  may  be  perverted  and  turned  to  an  evyll  use,  by 
them  that  be  evyll  and  naught  themselves,  and  so  abuse  it ; ne  is 
there  any  thyng  so  absolute  and  perfecte,  but  by  the  occasion  of  the 
abuse  therof,  at  one  tyme  or  other,  may  and  doth  ensue  great 
daunger  and  damage  to  mankynde.  Fyre  and  Avater  be  Hvo  right 
necessary  elementtes  to  the  use  of  man,  Avithout  the  Avhiche  AA^e  coulde 
not  lyve  : yet  by  the  meanes  of  them  many  a miserable  deede  hath 
been  done  and  perpetrated.  By  fyre  hath  ben  consumed  and 
devoured  Avhole  Cities  and  Countries.  By  Avater,  sAvaloAved  and 
drowned  infinite  men,  shippes,  yea,  and  Avhole  regions.  Agayne,” 
he  continues,  “ meate  and  drynke,  to  the  moderate  users  therof, 
doth  minister  and  maynteyne  lyfe ; And  contrary,  to  the  unmea- 
surable and  unsaciate  gourmauntes  and  gluttons,  it  hath  full  many 
thousand  times  brought  surfeetes,  sickenesse,  and  at  the  laste, 
death.”  * * * * be  argues,  “ shoulde  men,  for  the 

avoydyng  al  these  foresayde  inconveniences,  and  for  the  reasons 
abovesayde,  condempne  and  bannysh  fyre  and  Avater,  forsake  theyr 
meate  and  drynke  ? * * * ^ No,  it  Avere  but  madnesse  once 

to  thinke  it.  Therefore  I say,  the  judgment  of  that  eye  can  never 
be  eqall  and  indifferent,  Avhiche  hath  more  respecte  and  regarde 
alwayes  to  the  displeasures  and  hurtes  possible  to  happen  (only 
through  the  misuse  of  a thyng)  than  to  the  emolumentes  and 
profites  dayly  and  commonlye  lyke  to  ensue  to  the  Avell  users  of  the 
same.  That  that  of  it  selfe  is  good,  is  never  to  be  disalowed  for  the 
sake  of  them  that  do  abuse  it.  For  * * ^ to  them  that 

be  good  them  selfe,  every  thyng  turneth  to  good,  whatever  it  be,  is 


116 


DEFENCES  OF  ANAESTHESIA 


to  them  a sufficient  matter  and  occasion  therein  to  seeke  the  glory 
of  God,  and  the  onely  profyte  of  theyr  even  Christen.  And  con- 
trary, suche  as  be  of  an  yll  disposition,  in  every  thyng  (he  it  never 
so  good  and  salutarie),  picketh  out  matter  of  maynteynaunce  to  theyr 
lewdnesse,  turning  matters  of  sadnesse  and  discretion  to  foolyshe 
and  pyvyshe  pratyng  contention.”  ^ 


^ Prologue  to  Raynalde’s  Birth  of  Manfcindey  Edition  of  1565,  p.  9. 


IN  MIDWIFEHY. 


117 


CHAPTER  VIII. 

ANSWER  TO  THE  OBJECTIONS  TO  ANESTHESIA  IN  MIDWIFERY, 
ADDUCED  BY  PROFESSOR  MEIGS  OF  PHILADELPHIA. 

Edinburgh,  August  1848. 

My  dear  Sir — A few  days  ago,  I saw  your  excellent  epistle  to  me 
on  the  use  of  anaesthesia  in  midwifery,  extracted,  in  an  abridged 
form,  from  the  Philadelphia  Medical  Examiner  of  March  last,  into 
the  London  Medical  Gazette  and  Lancet.  It  reminded  me,  that  amid 
other  avocations  and  work,  I had  hitherto  indolently  omitted  to 
answer  the  objections  contained  in  your  able  and  kind  letter.  And 
I feel  that  I am  the  more  to  blame  for  this  neglect — on  one  account 
— namely,  that  as  in  your  own  country,  so  also  in  ours,  there  are 
few  or  no  living  obstetricians,  whose  opinions  and  name  carry,  and 
deservedly  carry,  more  weight  with  them  than  yours.  Be  so  good, 
then,  as  bear  with  me  now  for  a few  minutes,  while  I endeavour  to 
state  in  what  respects  I am  inclined  to  demur  to  your  arguments 
against  anaesthetic  midwifery. 

On  reperusing,  as  I have  just  done,  your  esteemed  letter,  it 
appears  to  me  that  in  it  you  ground  your  opposition  to  the  adoption 
of  anaesthesia  in  midwifery  upon  four  or  five  different  arguments, 
although  you  do  not  specialise  them.  I shall  notice  each  of  these 
arguments  separately.  You  have  not  placed  them  in  any  particular 
order.  I shall  begin  first  with  the  one  which  you  placed  last. 

1.  You  object  to  anaesthesia  in  deliveries  reipiiring  chirurgical 
intervention”  and  especially  in  forceps  operations,  on  the  ground  thcd 
the  sensations  of  the  patient  afford  us  our  best  aid  for  the  introduction 
of  the  instrument. 

In  order  to  introduce  the  forceps  with  the  greatest  safety  to  the 
mother,  you  state  that — to  quote  your  own  words — “ the  best  guide 
of  the  accoucheur  is  the  reply  of  the  patient  to  his  interrogatory, 
‘Does  it  hurt  you?’  The  patient’s  reply,  ‘Yes’  or  ‘No,’  are,”  you 
observe,  “ worth  a thousand  dogmas  and  precepts.  I cannot,  there- 


118 


DEFENCES  OF  ANESTHESIA 


fore,”  you  continue,  “deem  myself  justified  in  casting  away  my 
safest  and  most  trustworthy  diagnosis,  for  the  questionable  equiva- 
lent of  ten  minutes’  exemption  from  pain,  which,  even  in  this  case, 
is  a physiological  pain.” 

In  answer  to  this  novel  objection,  you  will  excuse  me  when  I 
say,  for  I say  it  most  conscientiously,  that  I think  every  man  who 
ventures  to  use  the  forceps,,  in  any  midwifery  case,  ought  to  know 
the  anatomy  of  the  parts  implicated,  a thousand-fold  better  than  you 
here  presuppose.  You  would  have  the  accoucheur  guide  his  instru- 
ment, not  so  much  by  his  own  anatomical  knowledge,  as  by  the 
feelings  and  sensations  of  his  patient.  In  this,  as  in  other  points, 
relative  to  any  novel  question  in  practice,  we  can  often,  it  appears 
to  me,  best  perceive  the  soundness  or  unsoundness  of  our  views  upon 
it,  by  considering  and  contrasting  them  with  our  established  views 
on  other  analogous  questions,  regarding  which  the  opinions  of  the 
profession  have  been  long  ago  fixed  and  determined.  Now,  what 
would  the  surgical  world,  at  this  time  of  day,  think  of  an  operator, 
who,  in  making  a ligature  of  a large  artery,  such  as  the  humeral, 
placed  his  cliance  of  discriminating  the  attendant  nerve  from  the 
blood-vessel  which  he  wished  to  tie,  by  appealing,  not  to  his  own 
anatomical  knowledge,  but  to  the  feelings  of  his  patient,  as  he 
touched  the  suspected  structures.  “ Does  it  hurt  you  % — Yes,  or 
No.”  Would  not  our  surgical  brethren  denounce  and  decry  the 
capabilities  of  any  man  who,  in  operating,  required  to  have  recourse 
to  such  imperfect  and  incompetent  means  for  his  anatomical  direc- 
tion and  diagnosis  ? Would  it  be  right  and  moral  in  a surgeon  to 
deny  to  his  patients  the  advantages  of  anaesthesia,  in  order  that 
their  sensations  and  sufferings  should  make  up  for  his  want  of 
anatomical  and  operative  knowledge  % 

But  in  saying  this,  do  not,  I pray  you,  for  one  moment  suppose 
that  I fancy  that  the  argument  which  you  adduce  betrays  any  want 
whatever  of  the  highest  degree  of  operative  skill  on  your  part. 
Nothing  could  be  farther  from  my  thoughts.  And,  to  confess  the 
truth,  I do  sincerely  believe  that  you  yourself,  while  using  the 
forceps,  do  not  require  to  have  recourse  to  any  such  rude  rule  as  you 
here  propound — and  that,  in  fact,  the  rule  itself,  and  the  objection 
to  anaesthesia  in  operative  midwifery  which  it  contains,  is  an  after- 
thoiight  on  your  part,  which  has  only  sprung  up  since  the  practice 
of  anaesthesia  was  proposed.  For,  in  looking  over  the  excellent 
precepts  which  you  have  given,  relative  to  the  use  of  the  forceps,  in 
the  valuable  work  on  Midwifery  which  you  published  a few  years 


IN  MIDWIFERY. 


110 


ago — viz.  the  Philadelphia  Practice  of  Midwifery — I find  no  trace,  or 
mention  whatever  of  such  a rule  as  you  have  quoted  above  in  your 
letter  to  me.  If  that  rule  really  formed,  as  you  now  state,  the 
“ safest  and  most  trustworthy  ” guide  in  the  operation,  you  would 
certainly  have  at  least  noticed  it,  or  alluded  to  it  in  some  way.  In 
the  precepts  which  you  laid  down  in  your  work,  you  would  assuredly 
not  have  forgot  that  one  rule  which,  you  say,  is  worth  a “ thousand 
other  dogmas  and  precepts.”  And  it  would,  I think,  have  been 
only  the  more  incumbent  upon  you  to  have  mentioned  it,  seeing 
that  all  other  authors  omit  the  notice  of  it. 

I feel  assured  thatwhen  you  come  to  re-consider,  “dispassionatel}^” 
your  opinions  regarding  the  non-employment  of  an£esthesia  in 
operative  midwifery,  you  will  alter  these  opinions.  And  when  you 
come  to  employ  anaesthesia  in  actual  practice,  in  cases  in  which  the 
forceps  are  used,  you  will  find  that,  instead  of  impeding  the  applica- 
tion of  instruments,  the  anaesthetic  state  very  greatly  facilitates  it. 
It  enables  you  to  guide  the  forceps  far  more  safely  to  their  destina- 
tion, because  it  enables  you,  without  any  pain  to  the  patient,  to 
introduce  your  fingers  for  this  purpose  far  more  deeply  between  the 
head  and  maternal  structures  than  you  could  do  if  the  patient  were 
awake,  and  in  her  usual  sensitive  state.  You  yourself  state,  in  your 
published  work  on  Midwifery,  that  care  should  be  “ taken  to  direct 
the  point  [of  the  forceps]  by  the  two  fingers,  as  far  as  they  can 
reach”  (p.  300).  “.If,”  you  again  observe,  “any  difficulty  occurs  in 

getting  the  second  blade  forward  enough,  the  two  left  fingers  that 
are  guiding  it  will  serve  to  guide  it  edgeways  into  the  proper 
position.”  Now,  the  state  of  anaesthesia,  I repeat,  gives  you  (as  I 
have  several  times  found)  the  power  of  fulfilling  these  and  other 
most  important  rules,  to  an  extent  that  never  can  be  attained 
without  it ; and  I am  sure  you  will  find  them  worth  any  “ thousand 
dogmas  and  precepts”  derivable  from  the  mere  sensations  of  the 
patient. 

Besides,  these  sensations,  or  rather  the  expression  of  them,  would 
constantly  betray  you  if  you  did  place  any  dependence  upon  them. 
Under  the  same  amount  of  pain,  scarcely  any  two  women  would 
give  you  exactly  the  same  expression  of  suffering.  What  one 
woman  would  loudly  complain  of,  another  would  declare  to  be 
nought. 

Before  interfering  instrumentally  with  the  forceps,  the  labour 
has  generally  been  allowed  to  endure  for  twenty  or  thirty  long  hours. 
After  a poor  patient  has  undergone  such  a protracted  ordeal  of  pain 
64 


120 


DEFENCES  OF  ANESTHESIA 


and  suffering,  her  mind  is  not,  I fear,  in  general  in  a very  fit  state  to 
guide  the  operator  by  her  sensations  or  directions. 

At  page  302  of  your  published  work  on  midwifery,  you  state 
that  when  the  forceps  are  used,  the  patient’s  mind  is  naturally 
wound  up  to  a state  of  great  anxiety  ; “ it  is  strained,”  you  observe, 
“ to  the  highest  tension,  by  the  mere  thought  that  she  is  under  the 
operation.”  Now,  putting  entirely  out  of  view,  for  the  moment,  the 
propriety  of  our  saving  our  patients  the  increased  corporeal  agony 
attendant  upon  instrumental  delivery,  is  it  not,  let  me  ask,  our  right 
and  our  duty,  as  medical  men,  to  save  her,  as  we  can  do,  from  this 
trying  state  of  mental  anxiety  at  the  time  of  operating  ? In  most 
cases,  she  will  have  been  suffering  and  struggling  on  for  many  hours 
previously.  AVhy,  then,  thus  needlessly  and  greatly  intensify  both 
her  mental  anxieties  and  physical  sufferings  at  the  time  of  our  in- 
strumental interference,  when  her  strength,  alike  of  mind  and  body, 
is  perhaps  little  calculated  to  bear  any  increase  of  suffering ; and, 
above  all,  when  the  resources  of  our  art  furnish  us  with  simple  and 
certain  means  of  saving  her  from  the  unnecessary  endurance  of  the 
one  state  and  of  the  other  1 

But,  in  instrumental  delivery,  besides  greatly  facilitating  the 
application  of  the  forceps,  and  relieving  the  patient  from  enduring 
the  pains  of  the  operation,  and  that  “ highest  tension  ” of  mind 
which  is  present  during  it,  the  state  of  anaesthesia  saves  her,  I 
believe  also,  in  a great  measure,  from  the  effects  of  the  shock  of  the 
operation,  and  thus  gives  her  a better  chance  of  recovery.  If  we 
omit  it,  we  omit,  I believe,  not  only  a means  of  saving  her  from  the 
sufferings  attendant  upon  the  operation,  but  a means  of  saving  her 
from  some  of  the  dangers  attendant  upon  it.  When  first  publishing 
on  the  subject  of  anaesthesia  in  midwifery,  in  February  1847,  I 
offered  one  or  two  observations  on  this  point,  which  subsequent 
surgical  statistics  have  amply  fulfilled.  In  allusion  to  some  cases  of 
operative  delivery,  which  I recorded,  I observed  : — “ The  cases  I 
have  detailed  sufficiently  show  its  value  and  safety  in  cases  of  oper- 
ative midwifery.  And  here,  as  in  surgery,  its  utility  is  certainly  not 
confined  to  the  mere  suspension  and  abrogation  of  conscious  pain, 
great  as,  by  itself,  such  a boon  would  doubtless  be.  But,  in  modify- 
ing and  obliterating  the  state  of  conscious  pain,  the  nervous  shock 
otherwise  liable  to  be  produced  by  such  pain — particularly  whenever 
it  is  extreme,  and  intensely  waited  for  and  endured — is  saved  to  the 
constitution,  and  thus  an  escape  gained  from  many  evil  consequences 
that  are  apt  to  follow  in  its  train.” 


IN  MIDWIFERY. 


121 


The  observations  which  I have  hitherto  made  refer  entirely  to 
your  opinion  of  anaesthesia  in  instrumental  delivery.  But — 

2.  You  object  to  ancesthesia  in  natural  labours,  because  you  hold  that 
the  pain  of  natural  labour  should  not  be  annulled,  and  that  it  is  calcu- 
lated to  promote  the  safety  of  the  mother. 

You  regard,  you  say,  “ the  pain  of  a natural  labour  as  a state 
not  by  all  possible  means  and  always  to  be  eschewed  and  obviated,” 
— “ a labour  pain  being,”  you  declare,  “ a most  desirable,  salutary, 
and  conservative  manifestation  of  life-force.” 

In  the  above  expressions  you  make  no  distinction  between  the 
two  separate  and  distinct  elements  of  which  a so-called  labour  pain 
consists — viz.,  1.  The  contractions  of  the  uterus,  and  2.  The  sensa- 
tions of  pain  resulting  from  these  contractions.  If  you  apply  the 
language  I have  quoted  to  the  first  of  these  elements,  the  uterine 
contractions  (which  contractions  are  not  annulled  by  anoesthetics), 
I decidedly  and  entirely  agree  with  you.  If  you  apply  it,  however, 
to  the  sensations  of  pain  produced  by  the  uterine  contractions 
(which  sensations  are  annulled  by  ana3sthetics),  I most  decidedly  and 
entirely  dissent  from  your  opinion. 

In  your  work  on  midwifery,  you  make,  correctly,  the  important 
distinction  to  which  I refer.  You  state  (p.  148)  that  “the  word 
[labour]  is  highly  expressive  of  the  violent  and  painful  struggles  and 
efforts  of  the  woman.”  You  add  that  “ the  essential  element  of 
labour  is  the  contraction  of  the  muscular  fibres  of  the  womb.”  And, 
at  page  303,  in  speaking  of  the  strength  of  these  uterine  contrac- 
tions, you  observe,  “ Let  it  be  well  borne  in  mind  that  the  expulsive 
powers  of  the  womb  are  enormously  great.”  In  more  than  one 
place  in  your  wmrk,  you  allude  to  the  intensity  of  the  sensations  of 
pain,  “ the  pangs  and  agonies  of  travail,”  as  you  term  them  (p.  155) ; 
and  at  page  153  you  speak  of  the  “painful  sensations”  of  the 
mother,  in  the  last  part  of  labour,  as  so  great  in  degree,  “ as  to  be 
absolutely  indescribable  and  comparable  to  no  other  pain.”  In  your 
still  later  work  on  Female  Diseases,  speaking  of  these  pains — the 
pains  of  parturition — you  observe,  “Men  cannot  suffer  the  same 
pains  as  women.  What,”  you  continue,  “ do  you  call  the  pains  oi 
parturition  ? There  is  no  name  for  them  but  Agony.” 

The  muscular  contractions  of  the  uterus  form,  you  say,  the 
“ essential  element  ” of  labour.  In  that  opinion  you  and  I are  at 
one,  and  further,  I quite  agree  that  this  cannot  safely  be  “ eschewed 


122 


DEFENCES  OF  ANESTHESIA 


and  obviated  ” in  natural  labour ; nor  are  they  “ eschewed  and  ob- 
viated ” under  the  proper  use  of  chloroform. 

But  the  pain,  the  second  element,  is  a non-essential  in  the 
process.  It  is  non-essential,  because  — 1.  Labour,  that  is  the 
uterine  contractions,  are  occasionally,  though  very  rarely,  in  the 
course  of  practice,  seen  to  accomplish  the  full  expulsion  of  the  child 
with  little  or  no  pain  ; 2.  In  whole  tribes  of  the  human  race,  as  in 
some  of  the  black  tribes,  comparatively  little  or  no  pain  seems  to 
be  endured,  if  we  may  believe  various  authorities  ; and  3.  Hundreds 
of  women  have,  during  the  last  year,  been  delivered  with  perfect 
safety,  but  without  any  pain,  while  placed  under  the  influence  of 
anaesthetic  agents. 

I hold  the  pain  to  be  non-essential,  and  I protest  against  the 
truth  of  your  opinion  that  “ the  pain  of  a natural  labour  is  a state 
not  by  all  possible  means  to  be  eschewed  and  obviated.”  On  the 
contrary,  I maintain  that  we  omit  and  forego  a mighty  part  of 
our  professional  duties  whenever  we  forget  the  axiom  of  Bacon, 
that  “ it  is  the  office  of  a physician  not  only  to  restore  health,  but  to 
mitigate  pain  and  dolours.”  And  if,  as  medical  men,  we  are  called 
upon  to  mitigate  and  rem.ove  pain  of  any  degree  in  our  fellow-beings, 
we  are  surely  called  upon  to  mitigate  and  remove  those  “ pangs  and 
agonies  of  travail,”  as  you  term  them,  which  in  degree  are,  in  your 
own  language,  absolutely  indescribable  and  comparable  to  no  other 
pain,” — “pains  for  which  there  is  no  other  name  but  Agony.” 

In  your  practice,  you,  like  other  medical  men,  constantly  use 
measures  to  mitigate  and  relieve  the  pains  of  headache,  of  colic,  of 
sciatica,  of  pleurodyne,  of  gout,  rheumatism,  and  all  the  other  in- 
numerable “ dolours  ” that  flesh  is  heir  to.  Like  other  physicians, 
you  deem  it,  I doubt  not,  your  duty  to  wield  the  powers  of  your  art, 
in  order  to  free  those  that  submit  themselves  to  your  medical  care, 
from  these  and  from  other  similar  sufferings.  But  if  it  is  right  for’ 
you  to  relieve  and  remove  these  pains,  why  is  it  not  right  for  you 
also  to  relieve  and  remove  the  pains  accompanying  the  act  of  partu- 
rition ? I cannot  see  on  what  principle  of  philosophy,  or  morality, 
or  humanity,  a physician  should  consider  it  his  duty  to  alleviate  and 
abolish,  when  possible,  the  many  minor  pains  to  which  his  patients 
are  subject,  and  yet  should  consider  it  improper  to  alleviate  and 
abolish,  when  possible,  pains  of  so  aggravated  a character,  that,  in 
your  own  language,  they  are  “ absolutely  indescribable  and  com- 
parable to  no  other  pains,” — “ pains  for  which  there  is  no  other 
name  but  Agony.” 


IN  MIDWIFERY. 


123 


3.  You  object  to  anoestliesia  in  natural  labour,  because  you  deem  the 
min  of  natural  labour  a lohysiological  painy 

“ The  sensation  of  pain  in  labour  is,”  you  observe,  “ a physiolo- 
gical relative  of  the  power  or  force,”  and  “ to  be  in  natural  labour 
is  the  culminating  point  of  the  female  somatic  forces.” 

Now,  for  the  reasons  that  I have  already  stated,  I entirely  doubt 
if  we  should  look  upon  the  severe  sensations  of  pain  endured  by  our 
patients  as  truly  “ physiological,”  for,  as  I have  just  stated,  they  are 
not  essential  to  the  mechanism  and  completion  of  the  process  in  the 
white  races  of  mankind,  and  they  are  absent,  to  a great  degree,  in 
the  black.  The  severity  of  them  could,  I think,  be  easily  proved  to 
be  the  result  of  civilisation,  and,  as  I believe,  of  that  increased  size 
of  the  infantile  head  which  results  from  civilisation.  Parturition  is 
always  physiological  in  its  object,  but  not  in  some  of  the  phenomena 
and  peculiarities  which  attend  upon  it  in  civilised  life. 

But,  waiving  this  point,  or  the  discussion  of  it,  let  me  state,  that 
even  if  I allowed  all  the  intense  pains  of  parturition  to  be  “ phy- 
siological pains,”  I cannot  conceive  that  to  be  any  adequate  reason 
for  us  not  relieving  women  from  the  endurance  of  them.  Because 
nature  has  fashioned  any  particular  physiological  function  in  any 
particular  manner,  that,  I opine,  is  no  reason  why  the  science  and 
art  of  civilised  life  should  not,  when  possible,  alter  and  amend  its 
workings.  If  it  were  improper  for  us,  for  instance,  to  intermeddle 
with  the  functions  of  the  hair  of  the  head,  or  of  the  skin  generally, 
then  all  hats  and  other  coverings  for  the  scalp,  all  clothings  and 
coverings  for  the  body,  should  be  at  once  abandoned  and  uncon- 
ditionally condemned.  If  it  were  improper  for  us  to  alter  and 
amend  the  functions  of  the  eye,  then  all  optical  glasses,  the  tele- 
scope, the  microscope,  etc.,  must  be  thrown  aside.  And,  indeed,  not 
later  than  the  seventeenth  century  it  was  held  and  argued  so  in 
England.  For,  in  his  history  of  the  first  beginning  of  the  Eoyal 
Society  of  London,  Sprat  tells  us  that  it  was  generally  believed  that 
this  “ new  experimental  philosophy,  namely,  the  philosophical  papers 
laid  before  the  Society,  was  subversive  of  the  Christian  faith,”  and 
many,  he  adds,  mortally  hated  the  newly-invented  optical  glasses, 
the  telescope,  and  the  microscope,  as  atheistical  inventions,  which  per- 
verted our  organs  of  sight,  and  made  everything  appear  in  a new  and 
false  light  (DTsraeli).  You  argue  as  if  we  should  not  use  means  to 
eschew  the  pains  of  parturition  because  that  pain  is  physiological. 
AVhen  Columbus  first  discovered  your  mighty  American  continent, 


124 


DEFENCES  OF  ANAESTHESIA 


a large  portion  of  the  inhabitants  were  unprovided  with  any  hind  of 
dress  or  covering.  “ To  most  of  them,”  says  Eobertson,  “ nature  had 
not  even  suggested  any  idea  of  impropriety  in  being  altogether  un- 
covered.” And  I do  tliink  that  men  living  in  such  a state,  could, 
against  the  fashion  of  dressing,  use  with  far  greater  propriety  and 
consistency  than  you  or  me,  your  own  argument  against  anfesthetics 
in  labour.  Chloroform  and  ether  should  not  be  used  in  labour,  you 
argue,  because  the  pain  against  which  they  protect  us  is  natural  and 
physiological.  No  kinds  of  clothing  or  dress  should  be  used,  the 
original  Americans  might  have  equally  argued,  because  the  cold  or 
heat  against  which  they  j^rotect  us  is  natural  and  physiological. 

I have  a letter  lying  before  me  on  the  subject  of  anaesthetics  in 
midwifery,  by  a very  highly  and  very  justly  esteemed  teacher  of 
midwifery  in  Dublin.  “ I do  not,”  he  writes,  “ believe  that  any  one 
in  Dublin  has  as  yet  used  ether  in  midwifery  ; the  feeling  is  very 
strong  against  its  use  in  ordinary  cases,  and  merely  to  avert  the 
ordinary  amount  of  pain  which  the  Almighty  has  seen  fit — and  most 
wisely  we  cannot  doubt — to  allot  to  natural  labour;  and  in  this 
feeling  I heartily  and  entirely  concur.” 

The  argument  thus  used,  and  so  very  well  expressed  by  my 
Irish  correspondent,  is  one  which  has  been  often  adduced  and  re- 
peated during  the  course  of  the  past  year.  Some  minds  at  first  gave 
immense  weight  and  importance  to  it.  For  my  own  part,  I must 
confess  that  I never  could  view  it  as  possessing  any  great  force. 
Look  at  it  as  applied  to  any  other  practice  which  happens  to  be 
sufficiently  old  and  established  ; and  then  we  shall  see  it  in  its  true 
import.  Supposing,  for  example,  it  referred  to  the  first  introduction 
of  carriages  into  use  ; it  would  then  read  thus  : — “ I do  not  believe 
that  any  one  in  Dublin  has  as  yet  used  a carriage  in  locomotion  ; the 
feeling  here  is  very  strong  against  its  use  in  ordinary  jwogression,  and 
merely  to  avert  the  ordinary  amount  of  fatigue  which  the  Almighty 
has  seen  fit — and  most  wisely  we  cannot  doubt — to  allot  to  natural 
walking  ; and  iti  this  feeling  I heartily  and  entirely  concur.” 

Nay,  this  frequently-repeated  argument  against  new  innovations 
becomes  not  only,  I think,  ridiculous,  but  really  almost  irreverent, 
when  we  look  far  backward  into  the  march  of  civilisation,  and  apply 
it  to  any  practices  that  are  so  very  long  established  as  to  be  very 
antiquated,  and  with  which,  therefore,  the  human  mind  has  been 
long  and  intimately  familiarised.  Some  one,  but  who  I cannot 
pretend  to  say,  no  doubt  first  introduced  the  practice  of  wearing 
hats  or  bonnets,  or  some  covering  for  the  head.  Supposing  this 


IN  MIDAVIFERY. 


'125 


practice,  however,  stoutly  resisted,  as  doubtlessly  it  was  at  first,  then 
the  argument  of  my  Dublin  friend  against  this  innovation  would 
read  somewhat  as  follows  : — “ I do  not  believe  that  any  one  in  Dublin 
has  as  yet  used  a hat  to  protect  his  head  ; the  feeling  here  is  very 
strong  against  its  use  in  ordinary  weather,  and  merely  to  avert  the 
ordinary  amount  of  wetting  and  cold  which  the  Almighty  has  seen 
fit — and  most  wisely  we  cannot  doubt — to  allot  to  mankind  ; and 
ill  this  feeling  I heartily  and  entirely  concur.”  Some  day  a canal 
will,  in  all  probability,  be  made  through  the  Isthmus  of  Panama. 
It  has,  you  are  well  aware,  long  been  proposed  to  cut  one ; and 
there  and  thus  unite  the  Atlantic  and  Pacific  Oceans.  When  it  was 
proposed  in  the  sixteenth  century,  a priest  of  the  name  of  Acosta 
brought  forward  the  following  reason  against  it,  “ I am,”  said  he, 
writing  in  1588,  “of  opinion  that  human  power  should  not  be 
allowed  to  cut  through  the  strong  and  impenetrable  bounds  Avhich 
God  has  put  between  the  two  oceans,  of  mountains  and  iron  rocks, 
which  can  stand  the  fury  of  the  raging  seas.  And,  if  it  were  pos- 
sible, it  would  appear  to  me  very  just,  that  ^ve  should  fear  the 
vengeance  of  Heaven  for  attempting  to  improve  that  Avhich  the 
Creator  in  his  almighty  Avill  and  providence  has  ordained  from  the 
creation  of  the  Avorld.”  The  arguments  Avhich  are  here  brought 
forward  by  the  earnest  Spanish  priest,  against  man  meddling  with 
and  altering  the  impediments  to  navigation  caused  by  the  natural 
mechanism  of  the  Isthmus  of  Panama,  are  essentially  the  same  as 
those  lately  brought  forward  against  men  meddling  Avith  and  alter- 
ing the  agonies  -caused  by  the  natural  mechanism  of  parturition  in 
the  civilised  Avoman.  We  can  all,  perhaps,  at  this  time  of  day,  see 
through  raid  smile  at  the  character  of  the  old  priest’s  argument  Avith 
regard  to  the  supposed  impropriety  of  changing  and  cancelling,  if 
possible,  the  natural  obstruction  produced  by  any  isthmus.  Some 
years  after  this,  perhaps,  our  descendants  Avill  equally  see  through 
and  smile  at  the  analogous  modern  argument  in  regard  to  the  sup- 
posed impropriety  of  changing  and  cancelling,  Avhen  possible,  the 
physical  sulfering  produced  by  a physiological  function. 

The  truth  is,  all  the  tendencies  of  man,  in  a civilised  state  of 
society,  are  to  intermeddle  with  and  change,  and,  as  he  conceives, 
improve,  the  action  of  almost  every  function  in  the  body.  And  each 
such  improvement  has,  at  the  time  of  its  introduction,  been,  like 
the  practice  of  anaesthesia,  very  duly  denounced  as  improper,  im- 
pious, etc.  etc.  I might  refer  to  numerous  such  cases.  Let  me  cite 
only  one  example.  The  human  fingers  are  admirably  constructed 


126 


DEFENCES  OF  ANAESTHESIA 


by  our  Creator  for  the  function  of  seizing  and  lifting  objects.  The 
late  Sir  Charles  Bell  wrote  a whole  octavo  volume — a Bridgewater 
Treatise — on  the  mechanism  of  the  Jiuman  hand,  as  beautifully 
adapted  for  this  and  other  functions.  In  the  reign  of  the  earlier 
Stuarts,  forks  were  introduced  from  the  Continent  to  assist  our  hands 
in  the  act  or  function  of  seizing  and  lifting  the  divided  portions  of 
meat,  etc.,  that  we  wished  to  eat.  But  this  was  a very  sad  and 
uncalled-for  innovation  upon  the  old  and  established  physiological 
functions  of  the  human  fingers  ; and,  at  the  time,  it  was  as  loudly 
opposed  and  decried  as  the  modern  employment  of  anaesthetics  in 
aiding  the  physiological  function  of  human  parturition.  DTsraeli 
tells  us  that  the  use  of  forks  was  so  much  reprobated  in  some 
quarters,  that  some  uncleanly  preachers  denounced  it  “ as  an  insult 
on  Providence  not  to  touch  our  meat  with  our  fingers.”  Nature 
herself  has  provided  us  with  fingers  of  flesh  and  bone  and  nerve, 
* and  consequently,  is  it  not  unnatural  and  impious  in  man  to 
attempt,  in  his  human  pride  and  arrogance,  to  substitute  for  these, 
artificial  metallic  fingers  of  silver  and  steel  1 

I repeat — all  our  tendencies  and  workings,  in  the  present  state 
of  civilisation,  are  attempts  to  intermeddle  with,  and  change  and 
improve,  the  action  of  almost  every  function  in  the  economy.  And 
assuredly,  if  we  use  means  in  regard  to  the  function  of  parturition, 
with  the  view  of  ameliorating  and  abolishing  the  unnecessary,  but, 
as  you  call  them,  “ absolutely  indescribable”  pains  that  attend  upon 
it,  we  should  be  doing  nothing  more  than  what  you  and  I and  all  of 
us  are  ever  doing  in  relation  to  most  of  the  other  natural  or  physio- 
logical functions  of  our  own  bodies. 

Let  me  illustrate  this  last  remark  by  one  more  example,  for,  as 
I have  already  said,  it  is  only  in  this  way  that  we  can  properly 
judge  of  the  soundness  or  unsoundness  of  our  views  of  novel  points 
in  theory  or  practice.  You  are  well  aware  that  the  act  of  parturi- 
tion has  been  often  familiarly  compared,  as  the  late  Professor 
Hamilton  expressed  it,  “ to  the  toils  of  a journey,”  and  like  it 
divided  into  stages.  “ The  sufferings  of  the  mothers,”  says  he, 
“have  been  in  most  languages  compared  to  those  of  travellers.” 
Now  let  us  for  a moment  continue  this  natural  simile  between  the 
function  of  parturition  and  the  function  of  progression.  You  main- 
tain that  “labour  is  the  culminating  point  of  the  female  somatic 
forces.”  One  of  the  most  illustrious  Presidents  of  your  great 
American  Kepublic — Thomas  Jefferson — makes  in  his  memoirs  a 
remark  of  precisely  the  same  import  regarding  walking  or  progres- 


IN  MIDWIFERY. 


127 


sion.  He  describes  the  act  of  walking,  but  not  exactly  in  the  same 
words,  as  the  kind  of  “ culminating  point  of  the  human  somatic 
forces.”^ 

Few,  or  none,  perhaps,  will  question  the  abstract  truth  of 
Jefferson’s  observations  on  this  point.  But,  because  walking 
or  progression  is  a “ physiological  ” function,  and  the  practice  of  it 
is  reputed  salutary,  would  this  be,  with  you,  a proper  and  sufficient 
reason  for  never  setting  aside  or  superseding  in  any  way  this  “ phy- 
siological ” state,  in  the  same  way  as  you  insist,  on  the  same  grounds, 
that  the  physiological  pain  of  labour  should  not  be  set  aside  or 
superseded.  Because  progression  is  a natural  condition,  would  this 
be  any  adequate  reason  for  your  medical  advisers  adopting  your 
own  arguments  against  anaesthesia  in  midwifery,  and  insisting  upon 
this,  that,  the  next  time  you  travelled  from  your  own  city  of  Phila- 
delphia to  the  cities  of  Baltimore  or  New  York,  you  should  walk 
the  distance  on  foot  instead  of  travelling  it  by  railway  or  other 
conveyance  ? What  opinion  would  you  form  of  the  judgment  of  any 
medical  adviser  to  whom  you  entrusted  your  own  health,  if,  on 
going  next  time  to  the  New  York  or  Baltimore  railway  station,  he 
should  gravely  and  solemnly  repeat  to  you,  as  his  patient,  what  you 
tell  your  midwifery  patients,  and,  in  your  own  language,  advise  you 
to  try  to  accomplish  the  intended  journey  on  foot,  as  (to  quote  your 
own  words)  “ a desirable,  salutary,  and  conservative  manifestation 
of  life-force”'?  And  yet  this  would  really  be  nothing  more  than 
making  your  argumentum  ad  foeminam  an  argimentum  ad  hoiniium. 

You  state,  in  a passage  which  I have  already  quoted,  that  even 
the  agony  accompanying  instrumental  delivery  by  the  forceps  is  a 
“physiological  pain.”  I do  not,  I confess,  see  why  the  suffering 
attending  the  use  of  the  forceps,  when  the  head  is  impeded  by 
any  cause  of  obstruction,  should  be  regarded  as  a “ physiological 
pain,”  any  more  than  the  suffering  attending  the  use  of  the  catheter, 
in  obstruction  from  the  prostate  gland  or  other  morbid  conditions 
of  the  urethra,  should  be  regarded  as  a “ physiological  pain.”  They  are 

^ Since  writing  the  above,  I have  turned  up  Jefferson’s  Memoirs  to  get  his  own 
words.  “Walking,”  says  the  American  President,  “is  the  best  possible  exer- 
cise ; habituate  yourself  to  walk  very  far.  The  Europeans,”  he  continues,  “value 
themselves  on  having  subdued  the  horse  to  the  uses  of  man  ; but  I doubt  whether 
we  have  not  lost  more  than  we  have  gained  by  the  use  of  this  animal.  No  one 
has  occasioned  so  much  (as  the  horse)  the  degeneracy  of  the  human  body.  Our 
Indians  go  on  foot  nearly  as  far  in  a day,  for  a long  day,  as  an  enfeebled  white 
does  on  his  horse  ; and  he  (the  Indian),  wdll  tire  the  best  horses.” — Mcmoiy's, 
vol.  i.  p.  287. 


128 


DEFENCES  OF  ANAESTHESIA 


both  operations  intended  to  remove  the  natural  contents  of  the 
respective  viscera,  when  their  operative  removal  becomes  necessary. 

But  let  us  waive  this  point,  and  return  again  to  the  analogy 
between  the  functions  of  progression  and  parturition.  Suppose  you 
plead  with  your  medical  adviser  that,  instead  of  insisting  on  your 
going  on  foot,  they  should  allow  you  for  once  to  take  advantage  of 
artificial  assistance,  and  proceed  on  your  journey  from  Philadelphia 
to  Baltimore  or  New  York  by  railway,  because  you  were  unable  to 
walk  the  distance  in  consequence  of  being  incapacitated  by  a rheu- 
matic knee,  or  a sprained  ankle,  or  an  inflamed  or  blistered  toe,  and 
they  replied  to  you  that  you  should  not  care  for  this,  but  still  pro- 
ceed and  suffer,  because  the  pain  you  might  thus  suffer  was  (to  use 
again  your  own  language)  still  only  a “ physiological  pain.”  Would 
that  argument  be  any  adequate  philosophic  consolation  under  the 
endurance  of  your  suffering  1 or  would  you  not  laugh  at  the  logic 
of  your  medical  adviser,  and  take  your  seat  in  the  railway  in  spite 
of  his  doctrine  I And  I have  a fancy  that  betimes,  in  midwifery, 
patients  wi/l  learn  to  adopt  exactly  the  same  line  of  practice  under 
the  analogous  circumstances,  and  think  and  act  too  exactly  in  the 
same  way. 

4.  Fou  object  to  ancesthesia  in  labour,  because  the  mother,  in 
esca'pincj  by  it  from  the  “ 'pangs  and  agonies  of  labour,''  may,  in  a few 
rare  cases,  be  thus  made  to  encounter  danger  to  her  own  life. 

“ Should  I,”  you  observe,  “ exhibit  the  remedy  for  pain  to  a 
thousand  patients  in  labour,  merely  to  prevent  the  physiological 
pain,  and  for  no  other  motive,  and  if  I should,  in  consequence,  de- 
stroy only  one  of  them,  I should  feel  disposed  to  clothe  me  in  sack- 
cloth and  cast  ashes  on  my  head  for  the  remainder  of  my  days. 
What  sufficient  motive  have  I to  risk  the  life  or  the  death  of  one 
* in  a thousand  in  a questionable  attempt  to  abrogate  one  of  the 
general  conditions  of  man  1 ” Let  me  add  that  I have  seen  this 
argument  of  yours  already  repeated  from  your  letter,  and  strongly 
insisted  upon  by  the  opponents  of  ana3sthesia  in  this  countr}^ 

And,  indeed,  in  a new  practice,  such  as  that  of  anjesthesia,  and 
with  which  the  mind  is  yet  not  at  all  familiarised,  the  above 
forms  one  of  that  kind  of  apparently  strong  statements,  which 
it  is  impossible  to  answer  directly,  or,  indeed,  by  any  other 
way  than  by  taking,  as  I have  already  said,  a corresponding 
illustration  and  simile  from  some  other  matter  with  which  the 
mind  is  already  familiarised.  Let  us  for  a moment  longer 


IN  MIDWIFERY. 


129 


then,  adhere  to  the  familiar  comparison  which  I have  already 
taken  up,  under  the  last  head,  between  the  physiological  function  of 
human  parturition,  and  the  physiological  function  of  human  progres- 
sion. Suppose,  then,  that  you  and  I were  standing  at  the  Phila- 
delphia station  on  the  first  day  of  the  opening  of  the  railway  to 
Baltimore  or  New  York.  I wish  the  passengers  to  Baltimore  or 
New  York,  or  the  shorter  and  intermediate  stations,  to  proceed 
thither  by  railway ; but  you  argue  with  them,  like  President 
Jefferson,  that  “progression  is  the  culminating  point  of  the  human 
somatic  forces,”  and  that  “ walking  is  a desirable,  salutary,  and 
conservative  manifestation  of  life-force,”  and  that  progression  being 
a “physiological  function,”  and  fatigue  a physiological  pain,  they 
ought  to  proceed  on  foot.  I say  “ No.”  Place  yourself  in  a railway 
carriage,  and  thus  eschew  and  obviate  all  the  great  fatigue  and  use- 
less over-exertion  of  foot-travelling.  Then  comes  that  answer  and 
argument  of  j’Durs  which  I have  quoted,  and  which  runs  as  follows. 
“ But  should  I exhibit,  sir,  the  remedy  for  fatigue  (a  railway  carriagu) 
to  a thousand  travellers,  merely  to  prevent  the  physiological  exertion 
and  fatigue  of  walking,  and  for  no  other  motive,  and  if  I should,  in 
consequence,  destroy  only  one  of  them,  I should  feel  disposed  to 
clothe  me  in  sackcloth  and  cast  ashes  on  my  head  for  the  remainder 
of  my  days.  What  sufficient  motive  have  I to  risk  the  death  of  one  in 
a thousand,  in  a questionable  attempt  to  abrogate  one  of  the  general 
conditions  of  man — viz.  his  power  of  progression  by  walking]” 

I shall  not  stop  to  inquire  whether,  among  our  supposed  lady 
passengers  or  patients  (uninured,  as  most  of  them  are,  either  to  long 
pain  or  long  walking),  more  than  one  in  a thousand  would  not  be 
worn  out  and  destroyed  by  taking  the  journey  on  foot.  A less 
proportion,  I believe,  would  be  found  to  be  ultimately  destroyed  by 
the  perils  and  dangers  of  the  journey  by  railway  than  by  the  exer- 
tion and  fatigue  of  the  journey  on  foot,  and  the  Avalk  would  shake* 
and  damage,  both  temporarily  and  permanently,  many  more  consti- 
tutions than  the  railway  carriage.  I have  a firm  conviction  that,  on 
the  great  scale,  there  would  be  found  a more  absolute  saving  both  of 
human  life  and  of  human  health  by  adopting  the  means  invented  by 
art  than  the  means  provided  by  nature.  And  I most  firmly  believe 
that  yet  a similar  dilference  will  be  found  to  hold  good  between  the 
two  corresponding  practices  of  allowing  women  to  pass  through 
labour  afflicted  with  all  their  usual  physiological  “ pangs  and  agonies,” 
and  carrying  them  through  that  process  without  their  being  subjected 
to  the  endurance  of  these  pangs  and  agonies. 


130 


DEFENCES  OF  ANAESTHESIA 


But  I proceed  to  remark,  that  if  your  supposed  theory  with 
regard  to  the  function  of  parturition  were  carried  out  in  regard  to 
the  other  functions  of  the  human  body,  it  would  produce  a vast  and 
mighty  revolution  in  the  practices  of  civilised  life.  Follow  it  out,  for 
instance,  with  regard  to  any  one  of  them,  as,  for  example,  with  regard 
to  the  one  we  have  already  spoken  of,  viz,  progression,  and  see  what 
would  be  the  results.  Ever  and  anon  our  newspapers  contain  para- 
graphs, telling  us  of  one  or  more  human  lives  being  lost  by  collisions 
on  railways,  explosions  of  steamboats,  upsettings  of  stage-coaches,  etc. 
Consequently,  according  to  your  doctrine,  the  featherless  biped, 
pedestrian  man,  should  no  longer,  when  travelling,  fly  in  railway 
cars,  ply  in  steamboats,  ride  in  coaches,  etc.,  for  these  are  evidently 
all  so  many  questionable  attempts  to  abrogate  what  you  call  “ one 
of  the  general  conditions  of  man,  viz.  his  original  pedestrianism.” 

In  the  great  government  and  police  of  nature,  disease  and  death 
are  among  the  most  certain  “ general  conditions  of  man.”  If  your 
theory  were  true,  the  practice  of  medicine  itself  should,  I fear,  be  at 
once  and  summarily  abandoned,  for,  perhaps,  in  your  own  language, 
it  is,  at  best,  a questionable  attempt  to  abrogate  one  of  the  general 
conditions  of  man,  and  I am  sure  you  will  agree  with  me,  that  in  this 
“ questionable  attempt”  human  lives  are  often  lost  from  the  mistakes, 
or  the  passiveness,  or  the  want  of  knowledge  and  skill,  on  the  part 
of  the  physician.  In  England  and  Wales,  in  1840,  there  w^ere, 
according  to  the  returns  of  the  Eegistrar- General,  above  100  persons 
publicly  and  officially  reported  as  having  died  from  the  effects  of  one 
drug  alone,  opium.  But  would  this  be  any  reason,  or  any  ground 
of  reason,  for  abandoning  in  medicine  the  use  of  opium,  perhaps,  in 
itself,  the  most  valuable  of  all  the  remedies  in  our  pharmacopoeia  1 
Would  this  be  any  adequate  argument  for  refusing  to  relieve,  by  a 
dose  of  opium,  the  next  appropriate  case  of  pain  that  you  are  called 
to  ? Or  because  chloroform  or  ether,  in  a very  rare  case,  now  and 
again  produces  deleterious  or  even  fatal  consequences,  should  we 
refuse,  in  a thousand  other  persons,  to  mitigate  and  annul  their 
agonies  by  its  use  1 

In  your  esteemed  letter  to  me,  you  quote  some  remarks  from  the 
celebrated  old  work,  liaynalde’s  Birth  of  Manidnde,  the  first  book  on 
Midwifery  printed  in  English.  Look  at  the  Prologue  to  the  work. 
It  is  excellent  in  reference  to  the  very  matter  we  are  discussing — viz. 
whether  the  rare  accidents,  from  abuse  or  otherwise,  to  which  any 
good  gift  may  occasional!}'’  subject  those  who  use  it,  should  be  a 
reason  for  repudiating  tlie  general  use  of  that  gift.  “There  is  not 


IN  MIDWIFERY. 


131 


anything,”  says  Eaynalde,  “ so  absolute  and  perfecte,  but  by  the 
occasion  of  the  abuse  thereof  at  one  tyme  or  other,  may  and  doth 
ensue  greate  daunger  and  damage  to  mankynde.”  He  instances  fire 
and  water,  “ two  right  necessary  elementtes  to  the  use  of  man, 
without  the  whiche  he  could  not  lyve,”  yet  sometimes  “ by  fyre  hath 
ben  consumed  and  devoured  whole  cities  and  countreys.  By  water 
swalowed  and  drowned  infinite  men,  shippes,  yea  and  whole  regions. 
Agayne,”  he  continues,  “ meate  and  drynke,  to  the  moderate  users 
thej^eof,  doth  minister  and  maynteyn  life ; and  contrary,  to  the 
unmeasureable  and  unsatiate  gourmauntes  and  gluttons,  it  hath  full 
many  thousand  tymes  brought  surfettes,  sickenesse,  and  at  the  laste, 

death But,”  he  argues,  “ shoulde  men,  for  the  avoydyng 

al  these  foresade  inconveniences,  and  for  the  reasons  abovesayde, 
condempne  and  bannysh  fyre  and  water,  forsake  tlieyr  meate  and 
drynke  ] No,  it  were  hut  madnesse  once  to  iliinke  iV 

Before  passing  from  these,  your  supposed  dangers  of  anaesthetics, 
let  me  add  two  remarks — 1st,  I do  believe  that  if  improperly  and 
incautiously  given,  and  in  some  rare  idiosyncrasies,  ether  and  chloro- 
form may  prove  injurious  or  even  fatal — just  as  opium,  calomel, 
antimony,  and  every  other  strong  remedy  and  powerful  drug,  will 
occasionally  do.  Drinking  cold  water  itself  will  sometimes  produce 
death.  “ It  is  well  known,”  says  Dr.  Taylor,  in  his  excellent  work 
on  Medical  Jurisprudence,  “it  is  well  knowm  that  there  are  many 
cases  on  record,  in  which  cold  water,  swallowed  in  large  quantity, 
and  in  an  excited  state  of  the  systeni,  has  led  to  the  destruction  of 
life” — (p.  8).  Should  Ave,  therefore,  never  allay  our  thirst  Avith 
cold  .AA^ater  % What  AAmuld  the  disciples  of  Father  MattheAV  say  to 
this  1 But,  2dly,  You  and  others  have  very  unnecessary  aiid 
aggravated  fears  about  the  dangers  of  ether  and  chloroform,  and  in 
the  course  of  experience  you  Avill  find  these  fears  to  be,  in  a great 
measure,  perfectly  ideal  and  imaginary.  But  the  same  fears  have, 
in  the  first  instance,  been  conjured  up  against  almost  all  other 
innovations  in  medicine,  and  in  the  common  luxuries  of  life. 
Eevert  again  to  our  old  simile  regarding  travelling.  Cavendish, 
the  Secretary  to  Cardinal  Wolsey,  tells  us,  in  his  life  of  that  prelate, 
that  Avhen  the  Cardinal  Avas  banished  from  London  to  York  by  his 
master — that  regal  Eobespierre,  Henry  YIII. — many  of  the  Cardinal’s 
servants  refused  to  go  such  an  enormous  journey — “for  they  Avere,” 
says  Cavendish,  “ loath  to  abandon  their  natiAm  country,  their 
parents,  wives  and  children.”  The  journey,  Avhich  can  now  be 
accomplished  in  six  hours,  Avas  considered  then  a perfect  banishment. 


132 


DEFENCES  OF  AMSTHESIA 


We  travel  now  between  London  and  Edinburgh  (some  four  hundred 
miles)  in  twelve  or  fourteen  hours.  A century  ago  the  stage-coach 
took  twelve  or  fourteen  days.  And  in  his  life  of  Lord  Lough- 
borough, Lord  John  Campbell  tells  us  that  when  he  (the  biographer) 
first  travelled  from  Edinburgh  to  London,  in  the  mail-coach,  the 
time  was  reduced  to  three  nights  and  two  days;  “but,”  he  adds, 
“this  new  and  swift  travelling  from  the  Scotch  to  the  English 
capital  was  wonderful,  and  I was  gravely  advised,”  adds  Lord  John, 
“ to  stop  a day  at  York,  as  several  passengers  who  had  gone  tb  rough 
without  stopping  had  died  of  apoplexy  from  the  rapidity  of  the 
motion.” — Lives  of  the  Lord  Chancellors. 

Be  assured  that  many  of  the  cases  of  apoplexy,  etc.  etc.,  alleged 
to  arise  from  ether  and  chloroform,  have  as  veritable  an  etiology  as 
this  apoplexy  from  rapid  locomotion ; and  that-  a few  j^ears  hence 
they  will  stand  in  the  same  light  in  which  we  now  look  back  upon 
the  apoplexy  from  travelling  ten  miles  an  hour.  And  as  to  the 
supposed  great  moral  and  physical  evils  and  injuries  arising  from 
the  use  of  ether  and  chloroform,  they  will  by  and  by,  I believe, 
sound  much  in  the  same  way  as  the  supposed  great  moral  and 
physical  evils  and  injuries  arising  from  using  hackney  coaches, 
which  were  seriously  described  by  Taylor,  the  water  poet,  two  or 
three  centuries  ago,  when  these  coaches  were  first  introduced.  In 
his  diatribe  against  hackney  coaches,  Taylor  warned  his  fellow- 
creatures  to  avoid  them,  otherwise,  to  quote  his  own  words,  “ they 
would  find  their  bodies  tossed,  tumbled,  rumbled,  and  jumbled 
without  mercy.”  “ The  coach,”  says  he,  “ is  a close  hypocrite ; for 
it  hath  a cover  for  knavery;  they  (the  passengers)  are  carried^ back 
to  back  in  it  like  people  surprised  by  pirates ; and,  moreover,  it 
maketh  men  imitate  sea-crabs  in  being  drawn  sideways,”  and 
altogether  “it  is  a dangerous  carriage  for  the  commonwealth.” 
Then  he  proceeds  to  call  them  “ hell-carts,”  etc.,  and  vents  upon 
them  a great  deal  of  other  abuse,  very  much  of  the  same  kind  and 
character  as  tliat  lavished  against  anaesthetics  in  our  own  day. 

In  the  course  of  your  remarks,  you  imply,  I think,  though  you 
nowhere  explicitly  state,  another  objection  to  anaesthetics  in  mid- 
wifery, viz. — 

5.  You  object  to  anaesthesia  in  labour,  because  you  do  not  consider 
that  the  mother  encounters  danger  to  her  hecdth  or  life  from  the  endur- 
ance of  the  pcdns. 

“ I have  been  accustomed,”  you  observe,  “ to  look  upon  the  sen- 


IN  MIDWIFERY. 


133 


sation  of  pain  in  labour  as  a physiological  relative  of  the  power  of 
force,  and  notwithstanding  I have  seen  so  many  women  in  the  throes 
of  labour,  I have  always  regarded  a labour  pain  as  a most  desirable, 
salutary,  and  conservative  manifestation  of  life-force.” 

If  you  hold,  as  your  language  appears  to  me  to  imply,  that  the 
sensation  of  pain,  even  when,  as  in  labour,  the  degree  of  the  pain  is 
“ absolutely  indescribable,”  has  no  morbid  or  deleterious  influence 
upon  those  who  endure  it,  then  I most  decidedly  disagree  with  you. 
On  the  contrary,  I sincerely  believe  that  the  human  constitution  is 
so  constituted  that  it  cannot  endure  pain,  particularly  when  that 
pain  is  long  in  duration,  or  severe  in  degree,  without  being  more  or 
less  affected  and  injured  by  it.  I know  of  many  medical  and 
obstetric  authors,  from  the  time  of  Ambrose  Pare  down  to  the  time 
of  Travers,  Gooch,  Alison,  Burns,  etc.,  who  have  stated  and 
explained  the  common  and  hitherto  unchallenged  opinion  of  our 
profession  in  all  ages,  that  pain  was,  in  itself,  deleterious  and  de- 
structive, causing  depression  of  the  heart,  syncope,  and  even,  when 
in  excess,  sometimes  producing  speedy  and  sudden  death.  But,  till 
the  late  discovery  in  your  own  country  of  the  possibility  of  annul- 
ling the  pains  of  surgical  operations  by  the  inhalation  of  ether,  I 
know  of  no  writer  in  medicine,  in  surgery,  or  in  midwifery,  who 
held  that  pain,  Avhen  “ absolutely  indescribable  ” in  degree,  was  a 
matter  of  no  importance  in  regard  to  the  life  or  health  of  the 
sufferer,  and  should  not  be  relieved  even  when  we  had  the  complete 
power  of  relieving  it. 

If  the  mere  pain  of  the  labour  were,  as  you  state,  a “ desirable, 
salutary,  and  conservative  manifestation  of  life-force,”  its  long  con- 
tinuance, the  very  length  of  it,  would  insure,  more  certainly,  the 
health  and  safety  of  the  patient,  than  its  shortness.  Anything 
“salutary  and  conservative”  to  the  constitution,  should  manifestly 
be  safe  in  proportion  to  the  length,  and  dangerous  in  proportion  to 
the  shortness,  of  the  duration.  But  as  far  as  regards  the  life  and 
health  of  the  mother,  the  pain  of  labour  is  perfectly  the  reverse  of 
all  this.  It  is  safe  in  proportion  to  its  shortness,  and  dangerous  in 
proportion  to  its  length.  In  the  Dublin  Hospital,  the  tables  of 
which  afford  the  only  data  on  this  point  that  I know  to  refer  to, 
when  the  women  were  four  hours  in  labour,  more  subsequently  died 
than  when  their  pain  did  not  exceed  two  hours  ; of  those  that  were 
eight  hours  in  labour,  more  subsequently  died  than  of  those  that* 
were  four  hours  ill ; of  those  that  were  ttvelve  hours  in  suffering, 
more  died  than  of  thofee  that  were  eight : and  so  on  in  a regular 


134 


DEFENCES  OF  ANAESTHESIA 


progression.  The  longer  this  supposed  “salutary  and  conservative 
manifestation  of  life-force,”  as  you  term  it,  the  greater  became  the 
mortality ; so  that,  in  the  long  run,  the  maternal  mortality  was 
fifty-fold  greater  among  the  women  that  were  above  thirty-six 
hours  ill,  than  among  those  who  were  only  two  hours  in  labour ; one 
in  every  six  of  the  former  dying  in  childbed,  and  only  one  out  of 
every  three  hundred  and  twenty  of  the  latter. 

Some  time  ago,  I published  a long  series  of  statistics,  tending  to 
show,  that  out  of  a large  collection  of  cases  of  the  same  operation, 
performed  with  and  without  anaesthesia,  those  who  were  operated 
on  under  anaesthesia,  and  consequently  without  the  usual  sufiering, 
recovered  in  a much  larger  proportion  than  those  who  had  the  same 
operation  performed  without  anaesthesia,  and  whose  constitutions 
were  subjected  to  the  endurance  of  the  usual  pains  and  agonies  of 
the  surgeon’s  knife.* 

The  same  result  holds  good,  I believe,  in  midwifery  as  in  sur- 
gery. Save  the  maternal  constitution,  either  by  natural  or  artificial 
anaesthesia,  from  the  endurance  of  the  pains  connected  with  parturi- 
tion, and  you  will  enhance  both  the  chances  of  her  recovery,  and 
the  facility  of  it.  Among  your  Red  Indian  and  other  uncivilised 
tribes,  the  parturient  female  does  not  suffer  the  same  amount  of  pain 
during  labour,  as  the  female  of  the  white  race  ; and  in  consequence 
of  this  escape,  they  recover  far  more  rapidly  from  the  effects  of 
parturition  ; nor  are  fatalities  at  all  common  among  them.  So  easy 
is  the  convalescence  among  uncivilised  tribes,  that  Strabo,  Marco 
Polo,  and  other  historians  and  travellers,  tell  us  of  whole  communi- 
ties in  which  the  husband  immediately  went  to  bed  for  a number  of 
days,  upon  the  birth  of  a child,  and  the  wife  watched  and  nursed 
him.  “ Tliey  that  write  the  history  of  America,”  says  Guillemeau, 
“ tell  of  the  women  in  that  country,  that,  as  soon  as  they ‘be  de- 
livered, they  presently  rise  up,  and  lay  their  husbands  in  their  room, 
who  are  used  and  attended  like  women  in  childbed.” 

Among  the  patients  who  have  been  delivered  in  Scotland  under 
ana-sthesia,  the  rapidity  of  the  stage  of  convalescence  has,  as  a general 
rule,  been  increased  in  a degree  that  seems  often  to  surprise  the 
patient  herself,  as  much  as  her  escape  from  the  labour  pains  them- 
selves. Many  of  my  obstetric  brethren  have  remarked  this  circum- 
stance to  me.  In  fact,  on  awaking  after  delivery,  the  patient  does 
*not  encounter  and  endure  the  usual  feelings  of  exhaustion  and 
fatigue.  Some  have  declared  to  me  that  they  have  felt  as  if  they 
^ See  ante,  Part  11.  Chap.  VR 


IN  MIDWIFEKY. 


135 


had  awoke  from  a refreshing  sleep.  And  when  we  consider  the  capa- 
bilities for  the  enduring  of  suffering  and  exertion  among  the  class  of 
patients  in  civilised  life  upon  whom  you  and  I attend,  perhaps  the 
propriety  for  employing  anaesthesia  during  labour  may  appear  more 
evident.  Unaccustomed  by  their  mode  of  life  to  much  pain  and 
fatigue,  patients  in  the  higher  ranks  of  life  are  not  fitted  to  endure 
either  of  them  Avith  the  same  power  or  the  same  impunity  as  the 
uncivilised  mother,  or  even  as  females  in  the  lower  and  hardier 
grades  of  civilised  society ; and  hence  there  is  the  greater  propriety 
and  necessity  in  the  physician  employing  all  the  means  of  his  art, 
so  as  to  save  them,  as  far  as  possible,  from  their  sufferings.  To 
illustrate  the  point,  let  us  revert  again  to  our  old  comparison  be- 
tween the  physiological  functions  of  progression  and  parturition. 
Let  us  compare,  for  a moment,  our  ideas  of  the  effects  of  fatigue 
from  Avalking  and  of  pain  from  parturition  upon  the  female  consti- 
tution ; and  surely  the  comparison  is  not  an  unfair  one  for  your 
views,  as  far  as  the  severity  of  the  effects  of  dlie  two  influences, 
physical  fatigue  and  physical  pain,  are  concerned,  for  surely  the 
effects  of  pain,  of  “ absolutely  indescribable  ” pain,  should  be  greater 
upon  the  constitution  than  mere  muscular  fatigue.  Suppose,  then, 
that  our  patients,  at  the  end  of  the  ninth  month  of  pregnancy,  had 
to  walk  on  foot  a continuous  journey  of  one,  two,  three,  six,  or  a 
dozen  or  more  hours’  duration — that  is,  of  five,  ten,  twenty,  or  thirty 
miles,  or  upAvards — instead  of  passing  through  a continuous  journey 
of  recurring  labour  pains  of  the  same  duration,  the  pains  gradually 
becoming  stronger,  and  latterly  becoming  “ absolutely  indescribable, 
and  comparable  Avith  no  other  pains  ” — Avhat  Avould  be  the  result 
Avith,  say,  one  hundred  ladies  of  the  upper  classes  of  society  ? Some 
of  them  might  be  little  or  not  at  all  affected  by  the  journey ; others, 
Aveak  perhaps  when  they  began,  Avould  suffer  more  or  less  severely 
from  it.  Not  a feAV  would  be  inclined,  sooner  or  later,  to  stop,  and 
beseech  you,  if  you  were  the  medical  attendant  upon  them,  to  saA^e 
them  from  farther  exertion  and  fatigue,  by  alloAving  them  to  be 
carried  or  coached  the  required  distance.  In  ansAver  to  their  solici- 
tations, Avould  you  console  them  by  telling  them  that,  after  all,  pro- 
gression was  a “ conservative  manifestation  ” of  life-force,  and  free 
from  danger,  or  Avould  you  take  the  other  vieAv,  and  give  them 
means  of  travelling  the  required  distance  by  carriage  or  rail  ? I am 
sure  you  would  have  recourse  not  to  the  former  but  to  the  latter, 
for  you  would  fear  and  dread  the  effects  of  fatigue  upon  the  fragile 
constitutions  of  your  lady  patients.  And  I repeat,  that  certainly 
65 


136 


DEFENCES  OF  ANAESTHESIA 


the  effects  of  the  endurance  of  pain  are  as  great,  if  not  greater,  upon 
the  constitution,  than  the  effects  of  the  endurance  of  fatigue.  But 
if  you  would  allow  your  patients  to  ride  the  supposed  journey,  in- 
stead of  unnecessarily  forcing  and  compelling  them  to  walk  it  on 
foot,  equally,  I think,  should  you  allow  them  to  escape  what  you 
term  the  “ pangs  and  agonies  of  travail,”  by  saving  them  by  chloro- 
form, or  other  ancesthetic  agents,  during  their  travail,  from  all  the 
unnecessary  endurance  of  these  pangs  and  agonies. 

You  state,  “ I have  not  yielded  to  several  solicitations,  as  to  the 
exhibition  [of  chloroform],  addressed  to  me  by  my  patients  in  labour.” 
If,  when  driving  out  into  the  country,  you  perchance  meet  one  of 
your  fair  patients,  a few  miles  from  Philadelphia,  walking  homeward, 
but  so  tired  and  way-worn  that  every  five  or  ten  minutes  she  stopped 
and  groaned  for  fatigue,  “ absolutely  indescribable,  and  comparable 
to  no  other  fatigue,”  I am  sure  you  would  consider  yourself  bound, 
on  the  principles  of  common  humanity,  not  to  withstand  her  “ soli- 
citations ” to  be  driven  home  in  your  carriage,  and  thus  relieved  of 
her  present  anxieties  and  suffering.  And  I cannot  see  why,  if  you 
do  this  (and  who  would  not  do  it  ?),  to  relieve  a patient  from  the 
mere  effects  of  fatigue,  you  could  refuse  to  relieve  the  same  lady 
when  in  “ the  pangs  and  agonies  of  travail,”  from  the  endurance  of 
pains  which  are,  in  your  own  words,  absolutely  “ indescribable,  and 
comparable  to  no  other  pains.” 

“ Perhaps,”  you  observe,  “ I am  cruel  in  taking  so  dispassionate 
a view  of  the  subject.”  Of  course,  it  would  ill  become  me  to  pass 
any  such  judgment  upon  you ; but  I feel  this,  that  you  and  I,  and 
other  teachers  of  midwifery,  are  placed,  in  reference  to  this  question, 
in  a position  far  more  fearfully  responsible  than  ordinary  medical 
practitioners.  The  ordinary  obstetric  practitioner  has  little  or  no 
power,  except  over  the  relief  or  the  perpetuation  (according  as  he 
may  choose  it)  of  the  sufferings  of  his  own  immediate  patients.  But 
you  and  I,  as  obstetrical  teachers,  may,  through  our  pupils,  have  the 
power  of  relieving  or  of  continuing  the  sufterings  of  whole  communi- 
ties. If,  perchance,  you  persist  for  some  years  longer  in  your  present 
opinion,  it  will  have  the  effect  of  inflicting  a large  amount  of  what 
I conscientiously  believe  and  know  to  be  altogether  unnecessary 
agony  and  suffering  upon  thousands  of  our  fellow-beings.  If  you 
review  and  alter  your  opinions  (which  I earnestly  hope  you  will  do), 
and  make  yourself  sufficiently  acquainted  with  the  peculiarities  in  the 
mode  of  action  and  mode  of  exhibition  of  chloroform  during  labour,  a 


IN  MIDWIFERY. 


137 


vast  proportion  of  human  suffering  may,  even  within  the  next  few 
years,  be  saved  by  your  happy  instrumentality  and  influence. 

Feeling,  as  I do  deeply,  the  great  responsibility,  in  this  respect, 
of  your  situation  and  of  mine,  I trust  you  will  kindly  pardon  and 
excuse  me,  if  anywhere  in  the  preceding  pages  I may  have  appeared 
to  defend  my  views  with  too  much  earnestness.  If  I had  to  rewrite 
or  revise  the  observations,  I would  perhaps. have  stated  them  more 
accurately ; but  I must  send  them  as  they  are.  And  along  with 
them  I beg  to  send,  also,  the  most  sincere  esteem  and  reiterated 
respects  of,  my  dear  sir,  yours  very  faithfully. 


J.  Y.  Simpson. 


138 


DEFENCES  OF  ANiESTHESIA 


CHAPTER  IX. 

REPLY  TO  OTHER  MINOR  OBJECTIONS  TO  ANESTHESIA  IN 
MIDWIFERY. 

Edinburgh,  February  1849. 

An  objection  to  the  employment  of  chloroform  in  midwifery,  on  the 
ground  of  alleged  indecencies  committed  by  patients  whilst  undar 
its  influence,  has  been  raised  by  Mr.  Gream.^  This  is  by  no  means 
a new  objection.  At  the  time  when  various  of  our  now  common 
articles  of  food  and  medicine  were  first  introduced  into  use,  these 
innovations  were  frequently  opposed  and  decried  on  exactly  the 
same  ground.  As  a general  rule,  this  was  an  argument  always  re- 
sorted to  by  weak  and  impure  minds,  when  they  could  find  no 
stronger  arguments  against  any  proposed  innovation  in  our  customs 
or  habits.  For  instance,  at  the  present  day,  no  one  imagines  or 
argues  that  the  eating  of  potatoes  is  liable  to  cause  in  those  who  eat 
them  any  indecency  of  word  or  action.  And  yet  that  was  one  of 
the  principal  arguments  maintained  by  the  unscrupulous  against  the 
use  of  potatoes  for  long  after  their  introduction.  In  his  “ Traditions,” 
Mr.  Chambers  states  that,  even  as  late  as  the  last  century,  there  was 
a prejudice  against  the  potato  for  this,  among  other  reasons — “ That 
it  was  a provocative  to  incontinence.”  A hundred  years  after  this 
our  successors  in  the  profession  will  probably  feel  as  much  surprised 
at  the  idea  of  the  use  of  chloroform  exciting  improper  words  and 
actions,  as  we  are  all  now  at  the  old  idea  of  the. use  of  potatoes  being 
attended  with  the  same  alleged  consequences.  I have  now  used 
upwards  of  2000  oz.  of  chloroform,  and  have  never  witnessed  any 
such  effects,  and  never  expect  to  witness  them.  In  a circular  letter 
of  Mr.  Gream  to  the  English  practitioners,  to  which  attention  has 
been  directed  by  Dr.  Gumming,^  Mr.  Gream  did  not  ask  for  any 
beneficial  effects  from  chloroform  that  his  correspondents  might 
have  seen ; he  asked  only  for  the  bad  effects ; he  wanted  to 
see  only  one  side  of  the  picture.  And,  doubtless,  he  would  be 

^ See  Remarks  on  the  Euxployment  of  Anaesthetic  Agents  in  Midwifery,  by  G. 
T.  Gream,  Clmrclnlls,  1848. 

2 See  Proceedings  of  Edinburgh  Obstetrical  Society,  February  14,  1849. 


IX  MIDWIFERY. 


139 


gratified  by  some  of  the  reports  given  him  ; for  I believe  from  what 
I occasionally  hear  from  some  parts  of  England,  that  in  many  dis- 
tricts and  towns  there  the  use  of  chloroform  is  still  greatly  mis- 
understood ; a bad  and  dangerous  article  is  often  used  under  the 
name  of  chloroform  ; the  article  imperfectly  and  improperly  exhibited  ; 
and  no  proper  care  and  precaution  used  in  its  exhibition.  But  still  the 
profession  would  take  any  report  from  Mr.  Gream  on  the  subject, 
cum  gmno  sails  inrmagno.  In  a former  amusing  pamphlet  on  the 
subject,  Mr.  Gream  proceeded  so  far  as  to  alter  the  official  report  in 
a case  of  death  from  chloroform  at  Aberdeen,  in  order  to  prove  to 
his  readers  that  those  who  used  chloroform  may  have  morbid  ad- 
hesions of  the  heart  to  the  pericardium.  In  the  report  given  in  to 
the  Law  or  Government  authorities  in  this  case,  it  was  stated  that 
there  existed  “ old  adhesions  ” between  the  heart  and  percardium 
which  required  to  be  forcibly  torn  asunder  with  the  finger.  Mr. 
Gream  pretended  to  quote  this  report  verbatim,  and  in  inverted 
'commas  ; but  he  carefully  omitted  the  word  “ old,”  etc.,  for  he 
wished  to  prove  to  the  ladies  who  read  his  pamphlet  that  these  peri- 
cardial adhesions  were  quite  recent,  and  the  effects  of  the  chloroform  ! 
Our  grandchildren  will,  no  doubt,  wonder  at  such  pathological  ratio- 
cination, even  with  the  omission  of  the  word  “ old  but  at  the 
present  day  it  is  calculated  to  teach  us  this  circumstance,  that  one 
who  could  tamper  with  an  official  and  public  document,  for  the 
purpose  mentioned,  will  have  little  hesitation  in  following  the  same 
course  with  any  private  documents  intrusted  to  him. 

In  Edinburgh,  chloroform  has  now  (1849)  been  exhibited,  I 
believe,  to  40,000  or  50,000  persons,  without  a single  accident  or 
deleterious  result,  traceable  to  its  use.  Perhaps  as  many  doses  of 
opium,  or  antimony,  or  calomel,  or  Epsom  salts  even,  or  any  other 
potent  medicine,  would  not  have  been  followed  by  results  equally 
innocuous.  Some  two  or  three  hundred  die  in  England  and  Wales 
every  year  of  the  effects  of  opium  and  other  medicines,  given  in 
improper  doses,  or  in  particular  idiosyncrasies ; and  when  the 
proper  use  of  chloroform  comes  to  be  better  understood,  it  wdll,  I 
believe,  stand  less  high  in  that  list  than  most  other  medicines  used ; 
while,  besides  saving  pain,  it  will  ultimately  be  found  to  save 
human  life  to  no  small  extent  in  surgery  and  midwifery.  One 
means  by  which  its  proper  mode  of  employment  will  become  more 
widely  spread  in  a few  years  is  that  our  medical  students,  who 
daily  see  its  use,  and  the  rules  for  using  it  practised  in  the  hos- 
pitals of  Edinburgh  and  London,  will  leave  their  studies,  and  com- 


140 


DEFENCES  OF  ANESTHESIA. 


mence  practice  with  all  the  knowledge  necessary  for  its  employment, 
and  without  any  of  the  fears  naturally  shown  by  those  wdio  are 
unacquainted  with  its  phenomena.  It  has  been  often  repeated  that 
in  Harvey’s  time  no  physician  who  was  above  forty  years  of  age 
would  believe  in  the  doctrine  of  the  circulation  ; and  new  medical 
theories  and  practices  were  very  seldom  adopted  by  men  beyond 
that  term.  Some  beyond  this  age  of  conversion  have  argued  and 
reasoned  on  the  subject  in  the  most  extraordinary  way.  For  in- 
stance, an  old  but  excellent  accoucheur.  Dr.  James  Eeid,*  in  a late 
discussion  on  the  subject  of  anaesthesia,  at  the  Westminster  Society, 
stated  that  he  had  used  chloroform  in  three  midwifery  cases,  and 
that  it  had  not  relieved  the  pains  of  labour.  Of  course  Dr.  Eeid’s 
argument  merely  and  simply  showed  one  thing,  that  he  was  ignorant 
of  the  mode  of  giving  it,  for  no  one  here  or  elsewhere,  who  knows 
anything  of  the  matter,  has  met  with  such  results.  And  the  most 
strange  results  were  often  ascribed  to  it.  In  fact,  if  anything  what- 
ever happened  to  the  mother  or  child  for  months,  it  mattered  not 
what,  it  is  by  some  of  our  English  friends  directly  ascribed  to 
chloroform.  It  produces  all  manner  of  medical,  and  some  surgical 
diseases.  If  the  child  has  a dislocation  or  fracture,  the  cause  is  the 
chloroform.  The  same  gentleman.  Dr.  lieid,  some  time  ago  men- 
tioned, at  the  same  Society,  the  case  of  a child  dead-born,  in  the 
practice  of  Dr.  Smith,  after  a very  long  labour  (forty  or  fifty  hours), 
and  where  the  mother  was  chloroformed.  The  child  died  in  conse- 
quence of  dislocation  or  fracture  of  the  lower  parts  of  the  parietal 
bone  against  some  projecting  point  or  other  in  the  interior  of  the 
maternal  pelvis.  But  the  death.  Dr.  Reid  argued,  was  from  chloro- 
form ; and  as  the  immediate  cause  of  death  was  the  above,  hence 
chloroform  could  produce  dislocation  or  fracture,  and  a hundred 
deleterious  results  besides.  I have  heard  chloroform  accused,  on 
equally  logical  grounds,  of  being  the  cause  of  a monstrosity  on 
the  part  of  the  foetus,  when  it  happened  to  be  given  at  the  birth  of 
the  malformed  child.  Certainly  not  many  years  will  elapse  ere  the 
profession  must  see  the  weakness  and  folly  of  this  mode  of  argu- 
ment. But,  as  it  stands,  no  newly-introduced  practice  has  ever,  I 
believe,  made  so  great  and  steady  progress  in  so  short  a tirpe  as 
anaesthetic  midwifery ; and  of  its  ultimate  and  entire  success  and 
adoption  everywhere,  no  obstetrician  in  Edinburgh,  where  all  witness 
and  practise  it,  has  any  kind  of  doubt. 

^ Lancet,  January  27,  1849. 


DIFFICULTIES  OF  SUPEIilNDUCTION. 


141 


CHAPTER  X. 

ALLEGED  DIFFICULTIES  IN  THE  SUPERINDUCTION  OP 
ANAESTHESIA. 


Edinburgh,  October  1848. 

I HAVE  been  occasionally  told  of  cases,  in  which  it  was  supposed 
that  it  was  impossible  to  produce  the  ansesthetic  effect  of  chloroform. 
In  my  own  practice  (and  I have  now  used  chloroform  in  many 
hundred  cases),  I have  never  yet  met  with  a single  instance  in 
which  a person  was  proof  against  its  full  influence. 

It  has  been  sometimes  averred,  in  the  English  journals,  that  on 
attempting  to  use  chloroform,  jactitation,  incoherent  talking  and 
delirium,  spasms,  etc.  etc.,  have  supervened,  instead  of  a state  of 
quiet  anaesthesia.  These  are  symptoms  which  do  occasionally  come 
on  in  the  first  or  exciting  stage  of  its  action,  more  especially  if  strict 
quietude  is  not  enjoined  ; and,  though  they  are  apt  to  terrify  the 
beginner,  they  are  in  reality  no  more  serious  in  their  effects  and 
, character,  than  some  of  the  equally  frightful  symptoms  sometimes 
seen  in  hysteria.  They  are  an  evidence,  however,  of  one  of  two 
things — either  that  the  vapour  is  being  given  too  slowly,  or  that  it 
is  given  in  two  small  quantity — in  an  exciting,  in  fact,  instead  of  a 
soporific  dose ; and  the  simple  remedy,  as  every  one  proj)erly  ex- 
perienced in  its  action  knows,  is  at  once  to  increase  the  dose  in  order 
to  pass  the  patient  as  speedily  as  possible  into  the  second  or  full 
narcotic  stage. 

Chloroform,  it  is  alleged,  sometimes  gives  rise  to  much  coughing, 
and  pulmonary  irritation.  Certainly  not  so,  if  the  chloroform  is  of 
good  quality,  and  its  vapour  is  not  at  first  approached  in  too  strong 
and  concentrated  a form  to  the  face  of  the  patient.  After  some 
experience,  it  will  be  found  that  it  can  be  given  so  as  seldom  or 
never  to  induce  even  coughing.  Some  time  ago,  a well-known  phy- 
sician, in  a large  city  of  the  south  of  England,  wrote  me,  that  he 
and  his  townsmen  had  found  it  too  dangerously  irritant  a substance 
to  breathe,  and  that  he  had  seen  it  produce  cough,  bronchitis, 
phthisis,  etc.  The  answer  was  simple  ; it  never  produced  any  such 


142 


DEFENCES  OF  ANESTHESIA. 


effects  in  Edinburgh  practice.  And  I believe  that  the  explanation 
was  equally  simple ; he  and  his  townsmen  had  experimented  with 
an  imperfect  and  impure  article.  A few  days  ago  one  of  the  prin- 
cipal druggists  in  Edinburgh  showed  Dr.  Christison,  Dr.  Donglas 
Maclagan,  and  myself,  a bottle  of  chloroform  of  high  specific 
gravity,  viz.  1*490,  which  he  had  just  received  from  a very  large 
manufacturing  chemical  house  in  London.  It  was  impossible  to 
breathe  it  without  feeling  great  irritation  in  the  throat  and  chest. 
It  emitted  fumes  that  at  once  reddened  litmus  paper;  and  which, 
on  examination,  proved  to  be  muriatic  acid.  Is  it  wonderful  that 
bronchitis,  coughs,  and  more  serious  disasters,  should  have  followed 
the  inhalation  of  such  an  improper  and  dangerous  article  ? 

Dr.  Letheby  has  shown  that  some  kinds  of  chloroform  in  the 
market,  besides  containing  muriatic  acid,  are  also  mixed  with  alde- 
hyde, hydrochloric  ether,  hypochlorous  acid,  etc.* 

^ See  Medical  Gazette  for  June  16,  1848,  p.  1038.  The  presence  of  some  of 
these  deleterious  agents  has  been  supposed  to  he  an  inevitable  and  speedy  effect  of 
the  spontaneous  decomposition  of  very  pure  chloroform.  But  I find  that  some  of 
the  article,  manufactured  several  months  ago,  in  its  purest  form,  by  Duncan,  Flock- 
hart,  and  Company,  of  this  city,  has  undergone  no  kind  of  change,  even  though  long 
exposed  to  the  sun.  Messrs.  Smith  have  also  shown  me  the  same,  in  regard  to 
their  chloroform.  I have  reason  to  know,  that  the  dangerous  article  alluded  to  in 
the  text  as  containing  a quantity  of  muriatic  acid,  has  been  extensively  sold  to  the 
profession,  throughout  Scotland  and  England,  at  a price  two  or  three  shillings 
per  pound  cheaper  than  is  charged  for  the  piu’e  chloroform  manufactured  by  other 
houses  ; and,  probably,  its  very  cheapness  has  led  to  its  extensive  use.  The  follow- 
ing is  the  formula  by  which  chloroform  is  prepared  by  Messrs.  Duncan,  Flockhart, 
and  Company,  of  Edinburgh,  whose  article  I have  always  found  of  the  most  superior 
quality  : — 4 pounds  of  chloride  of  lime,  and  12  pounds  of  water,  are  first  well 
mixed  together,  and  then  12  ounces  of  spirit  added.  Heat  is  then  applied  to  the 
still  (which  ought  not  to  be  more  than  a third  full),  but  as  soon  as  the  upper  part 
of  the  still  becomes  warm  the  heat  is  withdrawn,  and  the  action  allowed  to  go  on 
of  itself.  In  a short  time  the  distillation  commences,  and  Avhenever  it  begins  to 
go  on  slowly,  the  heat  is  again  applied.  The  fluid  which  passes  over  separates 
into  two  layers,  the  lower  of  which  is  chloroform.  This,  after  having  been  separated 
from  the  weak  spirit  forming  the  upper  layer,  is  mixed  with  half  its  measure  of 
strong  sulphuric  acid,  added  gradually.  The  mixture,  Avhen  cool,  is  poured  into  a 
leaden  retort,  and  distillatl  from  as  much  carbonate  of  baryta  by  weight,  as  there  is 
of  sulphuric  acid  by  measure.  The  product  should  be  allowed  to  stand  over  quick- 
lime for  a day  or  two,  and  repeatedly  shaken,  and  then  redistilled  from  the  lime. 
The  specific  gravity  of  the  resulting  chloroform  is  generally  1*496  or  1*497. 


DEATHS  FEOM  CHLOKOFOKM. 


143 


CHAPTER  XL 

REMARKS  ON  THE  OCCASIONAL  FATAL  RESULT  OF  THE  ADMINISTRA- 
TION OF  CHLOROFORM,  WITH  CASES  OF  SUDDEN  DEATH  DURING 

SURGICAL  OPERATIONS  WITHOUT  ANAESTHETICS. 

Edinhurgli,  June  9^/<,  1852. 

In  the  last  number  of  the  Medical  Times  and  Gazette,  Dr.  Snow  asks 
me  to  state  the  cases  of  death  from  chloroform  which  have  occurred 
in  Scotland. 

He  mentions  two  cases,  both  at  or  near  Glasgow ; one  under  the 
operation  of  extracting  a toe-nail,  the  other  while  sounding  for  stone. 
I do  not  know  any  particulars  whatever  as  to  the  former  case.  The 
common  current  account  of  the  latter  is  given  in  the  last  number  of 
the  Monthly  Medical  Journal,  page  554,  under  some  observations  on 
chloroform,  to  which  I beg  to  refer  your  correspondent. 

In  addition  to  these  two  cases,  I have  heard  only  of  one  more 
instance  of  a fatal  result  from  the  employment  of  chloroform  in 
surgery,  and  that  also  near  Glasgow.  In  this  instance,  chloroform 
was  given  by  the  practitioner  for  tooth-extraction ; but,  I am  sorry 
to  add,  none  of  the  parties  present  were  at  the  time  in  a condition 
to  give  any  very  satisfactory  evidence. 

These  are  the  only  cases,  so  far  as  I know,  of  death  in  Scotland 
from  chloroform,  among  the  many  thousand  cases  in  which  it  has 
now  been  exhibited  in  connection  with  surgical  proceedings  ! and  I 
believe,  that  if  any  others  had  occurred,  I should  have  been  certain 
to  have  heard  of  them. 

Before  chloroform  was  introduced,  sulphuric  ether  was  reported 
to  have  produced  the  death  of  one  patient  in  Scotland,  who  had 
amputation  of  the  thigh  performed,  in  consequence  of  a severe  rail- 
way injury.  One  of  the  surgeons,  however,  afterwards  assured  me, 
that  in  the  dark  hovel  in  which  the  operation  was  performed,  it  was 
found  impossible  to  secure  the  vessels  sufficiently  quickly  with  the 
ligatures  to  prevent  the  collapsed  patient  dying  from  hemorrhage 
after  the  leg  was  removed ; but  the  ether  was  a better  apology  than 
the  hemorrhage  for  the  man’s  sudden  sinking. 


144 


DEFENCES  OF  ANESTHESIA. 


I know  of  one  medical  patient  who  died  south  of  the  Tweed, 
when  using,  or  shortly  after  using,  chloroform,  to  procure  sleep  in 
delirium  tremens.  But,  as  Dr.  Snow  is  well  aware,  death  often 
enough  occurs  suddenly  in  that  disease ; and  the  last  thing  done  is 
always  apt  to  be  blamed  for  the  result.  A medical  friend  of  mine 
had,  some  time  ago,  a patient  suffering  under  delirium  tremens. 
Opiates,  etc.,  had  all  failed  to  produce  quietude,  or  induce  sleep.  At 
last,  the  practitioner  who  was  watching  by  his  patient,  went  home 
to  his  own  house,  which  was  in  the  immediate  neighbourhood,  to 
obtain  some  chloroform  for  the  purpose  of  using  it  as  a hypnotic. 
During  the  few  minutes  of  his  absence  in  search  of  the  chloroform- 
bottle,  his  patient  died. 

A somewhat  similar  coincidence  happened  at  the  very  first  intro- 
duction of  chloroform  here.  After  discovering  the  anaesthetic  effects 
of  chloroform,  I was,  of  course,  anxious  to'  get  it  tried  in  a surgical 
operation.  The  first  surgical  cases  in  which  it  was  used  were 
operated  upon  in  the  Royal  Infirmary  here,  on  15  th  November 
1847.  Two  days  previously  an  operation  took  place  in  the  In- 
firmary, at  which  I could  not  be  present,  to  test  the  power  of  chloro- 
form ; and,  so  far,  fortunately  so ; for  the  man  was  operated  upon 
for  hernia,  without  any  anaesthetic,  and  suddenly  died  after  the  first 
incision  was  made  through  the  skin,  and  with  the  operation  uncom- 
pleted. I know  of  another  case  in  Edinburgh  where  death  instan- 
taneously followed  the  use  of  an  abscess-lancet,  without  chloroform ; 
the  practitioner,  in  fact,  deeming  the  case  too  slight  to  require  any 
anaesthetic. 

While,  since  the  anaesthetic  effects  of  chloroform  were  known,  we 
have  thus  bad  two  patients  dying  in  Edinburgh  on  the  operating- 
table,  who  did  not  use  chloroform,  we  have  had  no  death  under  the 
same  circumstances  in  the  vast  number  who  have  now  taken  chloro- 
form here  for  surgical  operations  and  other  purposes. 

Some  time  ago  I was  informed  of  an  instance  in  which  a prac- 
titioner urged  a patient  to  use  chloroform  for  the  purpose  of  allowing 
a tooth  to  be  removed  that  had  worn  her  out  with  pain.  She  post- 
poned it  for  a few  hours ; and,  in  the  meantime,  went  to  bed  to 
procure,  if  possible,  some  rest.  On  going  to  her  room  an  hour  or 
two  subsequently,  she  was  found  dead.  In  this,  as  in  other  similar 
instances,  the  reputation  of  chloroform  had  a narrow  escape. 

In  the  different  discussions  that  have  taken  place,  in  this  country 
and  on  the  Continent,  regarding  chloroform  as  the  supposed  cause  of 
death  in  various  surgical  patients,  it  appears  to  me,  that  it  has  very 


DEATHS  FROM  CHLOROFORM. 


145 


generally  been  forgotten  that  patients  have  ever  and  anon  died 
during,  or  immediately  after,  operations,  long  before  the  time  of  the 
use  of  any  anaesthetics.  But,  when  such  cases  occur  now,  and  anaes- 
thetics do  happen  to  be  employed  in  them,  the  latter  are  always 
naturally,  though  perhaps  not  always  justly,  blamed.  I have  already 
alluded  to  two  such  cases  which  have  happened  in  Edinburgh  since 
the  time  chloroform  was  known  here  ; and,  doubtless,  if  chloroform 
had  been  employed  in  these  cases,  it  would  have  been  taxed  with  the 
fatal  result.  Shortly  before  the  first  of  these  cases,  my  friend  Dr. 
Eobertson  had  shaved  the  groin  of  a patient,  and  was  about  to  pro- 
ceed to  perform  the  operation  for  hernia,  when  the  patient  fainted, 
and  died  before  any  incision  was  made.  I have  been  told  of  various 
cases  by  other  surgeons,  where  the  patient  died  on  the  operating- 
table  before  the  days  of  ether  and  chloroform,  and  wdiere  the  result 
now  would  be  considered  by  many  as  tlie  palpable  and  indisputable 
effect  of  any  anaesthetic  the  patient  might  chance  to  use. 

In  making  this  remark,  I do  not,  of  course,  by  any  means  wish 
to  argue,  that  chloroform  may  not,  and  has  not  proved  fatal  vdien 
used  in  surgical  operations.  Nothing  could  be  farther  from  my 
thoughts  or  intentions. 

The  druggists  of  Edinburgh  have  sold,  I believe,  during  the  last 
four  or  five  years,  as  much  chloroform  to  the  medical  practitioners 
and  to  the  public  of  this  city,  as  would  produce  anaesthesia  in  one  or 
two  hundred  thousand  separate  instances  ; and,  indeed,  most  of  the 
practitioners  here  use  it  daily  for  diagnostic  and  other  purposes, 
surgical,  obstetrical,  and  medical. 

I am  sure  you  will  doubt  with  me,  whether  an  equal  amount  of 
full  doses  of  antimony,  or  of  opium,  or  even  of  Epsom  salts,  would 
not  have  been  followed  by  a greater  number  of  deaths  occurring, 
perhaps  more  slowly,  but,  probably,  also  more  surely.  And,  on  the 
contrary,  this  agent,  while,  like  all  other  medicinal  agents,  proving 
injurious  now  and  again  in  a rare  exceptional  case,  has,  I rejoice  to 
think,  been  already  the  means  of  saving,  during  the  last  few  years, 
a vast  amount  of  human  suffering,  and  by  that  means  no  small 
amount  also  of  human  life. 

I am  not  aware  of  any  death  in  Scotland  or  elsewhere  from  the 
use  of  chloroform  in  midwifery,  out  of  the  many  thousand  cases  in 
which  it  has  now  been  employed  in  the  old  and  new  world.  Nor, 
indeed,  does  the  obstetric  patient  run  anything  like  the  risk  of  the 
surgical  patient ; for,  in  midwifery,  though  the  anaesthetic  is  re- 


146 


DEFENCES  OF  ANAESTHESIA. 


quired  to  be  given  for  a far  longer  period,  it  does  not  require  to  be 
given  so  deeply  as  in  surgery. 

Since  November  1847,  I have  only  attended  twelve  cases  of 
labour  in  which  chloroform  was  not  used  during  delivery.  In  all 
my  other  cases  I have  employed  it ; and  none  of  those  patients,  I 
venture  to  say,  who  have  used  it,  would  again  choose  to  suffer  the 
unnecessary  pains  attendant  upon  labour  without  i*.  Most  of  my 
obstetric  brethren  employ  it  as  frequently  as  I do.  After  once 
beginning  its  use  at  an  obstetric  case,  I generally  leave  its  exhibition 
to  be  continued  by  the  nurse,  or  by  any  intelligent  friend  of  the 
patient  who  may  be  in  the  room.  Some  of  our  midwives  use  it  in 
the  cases  which  they  themselves  attend.  Two  weeks  ago  one  of 
them  told  me  that  she  had  now  employed  it  herself  in  her  own 
practice  in  above  fifty  cases,  with  nothing  but  the  happiest  results, 
and  without  meeting  with  any  circumstances  to  give  her  the  slightest 
feeling  of  uneasiness  in  its  employment. 

Chloroform  is  manufactured  to  a large  extent  by  three  or  four 
chemical  establishments  in  Edinburgh;  and  as  its  high  price  in 
England  has  been,  I believe,  one  great  cause  of  its  slow  introduction 
into  general  practice  among  you,  let  me  state,  that  with  us  it  is 
usually  sold  wholesale  to  apothecaries  at  six  or  seven  shillings  per 
pound  weight ; and  it  is  retailed  to  medical  men  at  eightpence,  and 
to  the  general  public  at  one  shilling  the  ounce  per  weight.  It  ought 
to  be  as  cheap  in  the  south. 

I am  not  aware  that  in  Scotland,  where  chloroform  is  employed 
so  very  extensively  and  so  very  successfully  by  medical  men  and 
others,  it  is  ever  exhibited  by  any  one  except  on  a handkerchief, 
towel,  or  the  like  ; no  kind  of  formal  apparatus  is  used.  Doubtless, 
one  principal  point  consists  in  diluting  its  vapour  sufficiently  freely 
with  air,  and  this  can  always  be  readily  accomplished  when  a hand- 
kerchief is  employed.  Some  American  and  English  practitioners 
have  proposed  to  render  the  vapour  of  chloroform  less  strong  by 
diluting  it  when  used  with  the  vapour  of  sulphuric  ether,  or  of 
alcohol,  as  in  the  so-called  chloric  ether.  But  alcohol,  etc.,  often 
leave  headache  and  excitement,  which  chloroform  does  not.  And  it 
is  surely  a thousand-fold  better  to  dilute  it  with  the  vapour  of 
“ common  atmospheric  air,”  than  with  any  other  diluting  medium. 

Perhaps  I should  add,  that  twice  or  thrice  chloroform  has  been 
used  in  Scotland  by  medical  men  and  others  to  commit  suicide ; 
but,  of  course.  Dr.  Snow’s  inquiry  does  not  extend  to  these  cases  of 
its  deliberate  abuse.  He  alludes  to  one  of  those  cases  in  which  a 


DEATHS  FKOM  CHLOKOFORM. 


147 


druggist  at  Aberdeen  destroyed  himself  by  “breathing  chloroform 
for  amusement  when  no  one  was  present and  he  proceeds  to 
speak  of  a fatal  accident  “from  this  proceeding”  as  a “matter  of 
course.”  I am  not  aware  of  any  other  similar  case  in  Scotland. 

Edinburgh,  1855. 

The  exhibition  of  chloroform,  as  of  every  other  potent  drug  used 
in  medicine,  is  liable  to  be  attended  with  danger  and  death,  pro- 
vided it  be  given  in  too  large  or  in  too  long-continued  doses. 
Like  most  other  valued  medicinal  agents,  it  is  powerful  for  evil  as 
well  as  for  good.  But  its  occasional  disagreement  with,  or  dele- 
terious influence  upon,  one  in  10,000  or  20,000  patients,  is  no 
sound  argument  against  other  patients  benefiting  from  its  employ- 
ment. It  has  been  calculated,  from  the  returns  of  the  Begistrar- 
General,  that  every  year  in  England  and  Wales  alone  some  300  or 
400  human  beings  are  poisoned  with  opiuni ; but  certainly  no  one 
would  argue  that  this  is  any  reason  why  opium,  the  most  valuable 
remedy  in  our  pharmacopoeia,  should  not  be  given  to  other  human 
beings  in  proper  doses  and  in  proper  cases.  Patients  have  often 
sunk  under  the  depressing  effects  of  calomel,  antimony,  digitalis, 
etc. ; but  such  accidents,  while  they  teach  us  very  strong  lessons  of 
caution,  form  no  reason  why  these  most  useful  drugs  should  be 
banished  from  the  pharmacopoeia.  Many  persons  are  annually 
drowned  in  bathing ; but  no  reasonable  man  would  argue  from  such 
unfortunate  occurrences  that  this  powerful  means  of  maintaining 
and  restoring  health  be  therefore  abandoned  and  forsaken.  Deaths 
certainly  ever  and  anon  occur  in  patients  subjected  to  the  influence 
of  chloroform,  but  assuredly  only  very  rarely  indeed  when  a pure 
drug  and  all  proper  precautions  are  used.  Perhaps  the  exhibition 
of  any  other  potent  medicinal  agent  in  the  materia  medica,  exhibited 
in  equally  full  doses  to  as  many  hundreds  of  thousands  of  patients 
as  have  now  inhaled  full  doses  of  chloroform,  would  have  been 
followed  by  more  accidents  and  deaths  than  have  been  witnessed 
in  the  use  of  this  ansesthetic  agent.  When  we  consider  the  im- 
mense  extent  to  which  chloroform  has  already  been  employed  in 
all  quarters  of  the  world,  in  medicine,  in  surgery,  and  in  midwifery, 
the  frequent  great  impurity  of  the  drug,  and  the  little  care  which 
has  sometimes  been  observed  in  its  use,  the  wonder  perhaps  really 
is,  that  so  few  accidents  have  happened  from  its  employment.  And 
as  a counterbalance  to  these  accidents,  we  know  from  statistical 
evidence  the  fact,  that  in  the  absolute  it  has  been  a great  means. 


148 


DEFENCES  OF  ANiESTIIESIA. 


not  only  of  saving  human  suffering,  but  also  of  saving  human  life, 
by  diminishing  in  a marked  ratio  the  danger  and  fatality  attendant 
upon  surgical  operations  and  diseased  states.  Thus,  let  us  take 
amputation  of  the  thigh  as  an  example.  Out  of  987  cases  of  this 
operation,  collected  by  Mr.  Phillips,  435  proved  fatal,  or  44  in 
every  100  died.  But  out  of  144  amputations  of  the  thigh  per- 
formed upon  patients  in  an  anaesthetic  state,  only  27  proved  fatal, 
or  25  in  100  died.  According  to  this  computation  the  number  of 
persons  saved  from  death  in  amputation  of  the  thigh  by  the  patients 
being  anaesthetised  during  the  operation,  amounts  to  1 9 lives  in 
every  100  operations  performed,  or  to  190  lives  out  of  every  1000 
such  operations. 

All  the  patients  that  die  under  the  hand  of  the  operator  when 
chloroform  is  used,  do  not  necessarily  die  from  the  effects  of  the 
chloroform  upon  the  constitution.  In  several  of  the  recorded  cases 
the  dose  given  was  far  ’too  small  to  have  had  any  such  fatal  effect. 
Before  the  time  that  anaesthetics  came  to  be  used  in  surgery,  deaths 
on  the  operation-table  ever  and  anon  occurred.  Such  cases  have 
been  recorded  by  Brodie,  Cooper,  Hom^e,  Travers,  etc.  etc.,  but  they 
excited  no  marked  share  of  professional  attention,  as  they  were 
generally  supposed  to  be  accidents  against  which  no  caution  could 
be  of  any  use.  Of  late  years,  and  since  chloroform  has  been  em- 
ployed, they  have  usually  been  directly  and  at  once  ascribed  to  the 
deleterious  action  of  the  chloroform. 


^ Edinburgh,  February  1870. 

A few  weeks  ago.  Dr.  Brotherston,  of  Alloa,  sent  into  Edinburgh 
a patient  who  was  the  subject  of  an  ovarian  tumour.  She  brought 
a note  from  him  asking  if  I thought  the  case  a fit  one  for  ovario- 
tomy. I wrote  back  that  it  seemed  to  me  to  be  so.  The  patient 
was  married,  about  twenty-two  years  of  age,  thin  and  emaciated, 
and  I thought  the  tumour,  which  was  as  large  as  the  pregnant 
uterus  at  the  sixth  or  seventh  month,  felt  more  solid  than  multilo- 
cular  ovarian  tumours  of  this  size  usually  do ; yet  it  seemed  free 
from  adhesions. 

Dr.  Brotherston  took  the  patient  into  the  small  village  Hospital 
at  Alloa,  and  urgently  requested  me  tor  be  present  when  he  opei*ated. 
Accordingly,  on  the  morning  of  February  5, 1 went  up  to  him.  Drs. 
Duncanson  and  Wilson  of  Alloa  were  also  to  be  present,  but  Dr. 
Duncanson  did  not  arrive  till  after  the  patient  was  laid  upon  the 
table  and  the  operation  begun.  With  the  view  of  allowing  Dr. 


DEATHS  FROM  CHLOROFORM. 


149 


Wilson  to  give  full  assistance  to  Dr.  Brotherston  at  the  operation,  I 
chloroformed  the  patient.  In  doing  so  I placed  a single  layer  of 
towel  over  the  nose  and  mouth,  leaving  the  eyes  exposed,  and 
dropped  the  chloroform  upon  the  towel.  When  Dr.  Brotherston 
made  his  first  cutaneous  incision,  the  patient  moved  so  much  that 
he  stopped  for  a brief  time  till  I put  the  patient  more  deeply  under 
the  effects  of  the  anaesthetic.  The, tumour  was  rapidly  reached,  and 
was  then  attempted  to  be  diminished  in  size  by  tapping,  but  only  a 
comparatively  small  quantity  of  fluid  escaped.  Dr.  Brotherston 
then  extended  the  opening  upwards  for  an  inch  or  more  above  the 
umbilicus,  and  was  introducing  and  using  his  hand  with  the  view  of 
turning  out  the  ovarian  mass,  when  the  patient  vomited  suddenly 
and  profusely.  Immediately  the  eyes  opened,  the  pupils  were  pre- 
ternaturally  dilated,  the  face  looked  pallid,  and  the  respiration,  which 
had  never  been  affected  by  the  chloroform  so  as  to  have  the  least 
noise  or  stertor  in  it,  seemed  arrested.  Instantly  artificial  respiration 
was  set  on  foot,  and  the  tongue  pulled  forward.  Deep  spontaneous 
respiration  then  occurred  several  times  in  succession,  and  I deemed 
at  the  moment  that  the  patient  was  hence  out  of  danger ; but  a 
second  collapse  occurred,  which  terminated  in  death,  all  means  of 
resuscitation  proving  unavailing. 

On  post-mortem  examination  of  the  body,  ordered  by  the  legal 
authorities,  no  diseased  conditions  could  be  found  in  the  head,  chest, 
or  elsewhere.  The  ovarian  tumour  was  free  from  any  peritoneal 
adhesions.  On  examining  its  structure.  Dr.  Pettigrew,  the  esteemed 
Pathologist  of  the  Royal  Infirmary  of  Edinburgh,  found  it  to  be 
cancerous  in  its  character. 

Remarks. — In  the  first  paper  which  I published  on  chloroform, 
December  1847,^  I stated  that  this  drug,  if  given  in  too  great  or 
too  long-continued  doses,  “ would  doubtless  produce  serious  conse- 
quences, and  even  death;”  and  at  the  same  time  I expressed  the 
hope  that  “ its  great  potency  would  be  one  great  safeguard  against 
its  abuse.”  Since  that  period  I have  exhibited  it  myself,  or  been 
present  when  it  was  exhibited,  in  several  thousands  of  instances,  but 
have  not  seen  its  employment  terminate  in  death  before  the  occur- 
rence of  the  preceding  unhappy  case. 

According  to  all  the  experimental  and  clinical  observations  which 
have  been  made,  chloroform  appears  capable  of  destroying  life  in  two 
ways — namely,  (1)  by  asphyxia,  and  (2)  by  syncope.  Death  by 
asphyxia  can  generally,  if  not  always,  be  averted  by  at  once  arrest- 
^ See  Edinburgh  Monthly  Journal  for  December  1847.  p.  415. 


150 


DEFENCES  OF  ANAESTHESIA. 


ing  the  inhalation  of  the  drug  whenever  the  breathing  becomes  noisy 
or  stertorous — states  which,  as  already  mentioned,  never  occurred 
with  the  preceding  patient.  Death  by  syncope,  or  sudden  stoppage 
of  the  action  of  the  heart,  is,  doubtless,  far  less  under  control,  and 
has  apparently  formed  the  principal  cause  of  the  fatal  issues  in 
nlmost  all  the  cases  in  which  patients  have  perished  when  under 
the  use  of  chloroform.  Perhaps  .fewer  cases  of  syncope  actually  do 
occur  under  operations  since  the  introduction  of  anaesthetics,  because 
the  nervous  and  sensory  systems  of  the  patients  are  so  far  obtunded 
by  their  employment  that  a patient  is,  I believe,  in  greater  jeopardy, 
if  syncope  do  happen,  when  he  is  under  the  influence  of  chloroform 
than  when  he  is  not  under  it,  because  the  irritability  and  action  of 
the  heart  are  diminished  by  the  free  use  of  it,  as  shown  by  the 
lowering  and  slowing  of  the  pulse.  Yet  when  syncope  does  occur 
in  chloroformed  persons,  artificial  respiration  and  its  accompaniments 
usually  are  sufficient  to  rally  and  restore  the  patient.  When  the 
preceding  case  was  described  by  me  at  a late  meeting  of  the  Edin- 
burgh Obstetrical  Society,  Dr.  Gordon  and  Dr.  Angus  Macdonald 
each  mentioned  an  instance  in  which  sudden  fainting  took  place, 
with  pallor  of  the  face,  open  eyes,  and  very  dilated  pupils,  at  the 
first  commencement  of  the  incisions  in  two  slight  operations — the 
one  for  the  removal  of  a small  tumour,  the  other  for  the  incision  of 
a carbuncle,  and  in  neither  case  had  the  patient  taken  any  unusual 
dose  of  chloroform.  They  both  recovered  under  artificial  respiration. 
Various  analogous  cases  have  been  recorded. 

But  are  all  such  cases  of  syncope  that  take  place  during  opera- 
tions, and  which  end  or  do  not  end  in  death,  the  result  of  the  action 
of  the  chloroform  which  happens  to  be  used  at  the  time  ] The 
question  is  one  which  has  never,  perhaps,  sufficiently  attracted  the 
attention  of  the  profession  ; for  doubtless  it  is  true  that,  antecedently 
to  the  introduction  of  anaesthetics,  patients  sometimes  died  from 
syncope  upon  the  operating-table,  both  immediately  before  and  after 
the  operation  was  commenced,  and  under  conditions  and  circum- 
stances which  in  modern  times,  when  anaesthetics  are  almost  univer- 
sally employed  in  operations,  would  be  not  unnaturally  described 
and  regarded  as  deaths  from  chloroform.  Formerly,  such  sudden 
deaths  under  surgical  operations  do  not  seem  to  have  been  looked 
upon  as  matters  of  moment,  because,  in  fact,  no  special  pathological 
or  practical  interest  was  attached  to  their  occurrence.  They  were 
simply  regarded  as  inevitable  accidents,  and  are  usually  only 
incidentally  alluded  to,  when  alluded  to  at  all  by  surgical  authors. 


DEATHS  FEOM  CHLOROFORM. 


151 


provided  they  illustrate  some  special  observation  or  opinion  on  the 
part  of  the  writer.  Thus,  as  showing  how  “ violence  alone  without 
the  loss  of  blood  may  often  produce  immediate  fatal  effects,”  John 
Hunter  makes  the  following  observation  : — 

Case  L — “ I have  seen,”  writes  Mr.  Hunter,  “ a man  thrown  into  such  con- 
vulsions from  the  operation  of  the  hydrocele  being  performed  upon  him,  that  I 
began  to  despair  of  his  recovery.”  “ I have  known,”  he  adds,  “ a man  die  im- 
mediately of  castration.”  (See  his  works,  vol.  iii.  p.  431.) 

In  the  first  volume  of  his  work  on  Constitutional  Irritation,  Mr. 
Travers  cites  several  cases  of  sudden  death  in  surgical  patients,  to 
illustrate  different  pathological  principles  to  which  he  points.  For 
example,  he  gives  the  following : — 

Case  II. — A robust  middle-aged  man,  the  subject  of  a moderate-sized  aneurism 
in  the  femoral  artery,  was  received  into  the  London  Hospital,  and  readily  assented 
to  the  usual  operation  for  that  disease.  On  entering  the  theatre,  however,  he 
fainted,  and  had  some  wine  and  water  given  to  him.  The  operation  was  tlien  pro- 
ceeded with  ; the  artery  was  exposed,  and  the  ligature  applied,  but  not  tightened. 
During  the  operation  it  was  observed  that  no  pulsation  could  be  felt  in  the  tumour, 
and  on  examining  the  patient  more  minutely  it  was  found  that  he  was  quite  dead. 
On  dissection,  both  sides  of  the  heart  were  found  empty,  and  the  lungs  turgid 
with  blood.  No  other  particular  appearance  was  observable. 

Case  III. — “I  saw,”  again  writes  Mr.  Travers,  “a  man  who  was  the  subject  of 
strangulated  hernia.  He  expired  suddenly  on  the  table  during  the  steps  pre- 
liminary to  the  operation,  which,  from  the  state  of  the  symptoms  and  of  the 
bowel,  as  ascertained  by  examination  after  death,  might  be  said  to  afford  the  fairest 
prospect  of  relief.” 

Case  IV. — A man,  who  had  been  bitten  in  the  finger  by  a cat,  and  in  whom 
symptoms  resembling  those  of  hydrophobia  had  been  present  for  twelve  hours, 
submitted  to  the  excision  of  the  bitten  part,  and  died  in  three  minutes. 

Case  Y. — A brewer’s  servant,  a man  of  middle  age  and  robust  frame,  suffered 
much  agony  for  several  days  from  a thecal  abscess,  occasioned  by  a sjfiinter  of 
wood  penetrating  beneath  the  nail  of  the  thumb.  A few  seconds  after  the  matter 
was  discharged  by  a deep  incision  he  raised  himself  by  a convulsive  effort  from  his 
bed,  and  instantly  expired.  (See  Travers  on  Constitutional  Irritation,  vol.  i. 
p.  25.) 

These  several  cases  are,  as  I have  said,  stated  by  Mr.  Travers, 
each  to  illustrate  some  special  pathological  principle  ; but  they  do  not 
necessarily  include  all  the  cases  of  sudden  death  upon  the  operating- 
table  which  he  may  have  seen  or  heard  of,  and  which  were  not 
calculated,  in  his  opinion,  to  point  to  any  special  surgical  fact.  In 
former  years,  in  talking  with  surgeons  who  had  seen  many  023era- 
tions  before  the  time  of  anaesthetics,  I heard  of  various  instances  in 
which  patients  had  been  removed  dead  from  the  operating-table. 
It  is,  perhaps,  impossible  now  to  collect  adequate  data  to  fix  the 
66 


152 


DEFENCES  OF  ANESTHESIA. 


probable  frequency  with  which  such  accidents  formerly  happened. 
We  may,  perhaps,  fairly  infer,  however,  that  they  Avere  not  very 
rare,  for,  when  attending  specially  to  this  question  in  the  first  six 
or  eight  years  of  anaesthesia  in  surgery,  the  following  cases  occurred 
in  Edinburgh  and  its  neighbourhood. 

Case  VI. — Shortly  before  the  introduction  of  anaesthetics  into  surgical  practice 
in  1846,  my  late  friend,  Dr.  John  Argyll  Robertson,  lecturer  on  surgery,  was 
asked  to  see  a case  of  strangulated  inguinal  hernia  in  the  practice  of  Dr,  Thomson. 
The  gentleman  was  removed  from  bed,  and  placed  upon  a table  to  facilitate  the 
required  operation.  Dr,  Robertson,  before  proceeding  to  use  his  scalpel,  was 
employed  in  removing  the  hairs  from  the  groin  with  a razor,  when  the  patient 
suddenly  complained  of  faintness,  gasped,  and  died. 

Case  VII. — After  discovering  the  anaesthetic  effects  of  chloroform  in  November 
1847,  I tested  it  in  a case  of  tooth-pulling,  but  required  to  wait  eight  days  before 
I had  an  opportunity  of  using  it  in  the  hospital  or  elsewhere  in  any  surgical 
operations.  A few  days,  however,  after  its  discovery,  a hernia,  which  had  been 
strangulated  for  a few  hours,  was  brought  into  the  Infirmary,  and  Professor 
Miller  thought  it  a case  demanding  operative  interference,  and  one  on  which 
chloroform  should  be  tried.  But  I could  not  be  found  in  time  for  the  purpose  of 
giving  it,  and  the  patient  was  operated  on  Avithout  any  anaesthetic.  Professor 
Miller  had  only  proceeded  the  length  of  dividing  the  skin,  when  the  patient 
fainted,  and  died  with  the  operation  unfinished.  If  the  chloroform  had  happened 
to  be  used,  and  this  fatal  syncope  had  occurred  while  the  patient  was  under  its 
action,  the  whole  career  of  the  new  anaesthetic  would  have  been  at  once  arrested. 

Case  VIII. — Within  a year  or  two  afterwards,  I saw,  at  my  own  house,  a child 
with  a large  abscess  in  the  neck,  and  I wrote  to  Dr.  Pattison,  the  medical  attend- 
ant, to  the  effect  that  I thought  it  was  sufficiently  advanced  to  be  opened.  Next 
day,  when  about  to  open  the  collection  of  pus,  the  mother  suggested  that  the 
child  should  first  have  some  chloroform  exhibited  to  it.  Dr.  Pattison  had  none 
Avith  him,  explained  that  the  walls  of  the  abscess  were  so  thin  that  the  operation 
would  not  give  much  pain,  and  put  his  lancet  into  the  purulent  swelling.  The 
child  immediately  fainted,  and  died,  without  any  hemorrhage  or  any  other  com- 
plication to  account  for  the  fatal  syncope. 

Case  IX. — In  a case  belonging  to  Dr.  Gilchrist,  of  Leith,  I saw  a surgeon  try 
to  treat  a sacculated  aneurism  at  the  root  of  the  neck  by  a small  quantity  of 
hemostatic  injection.  As  the  operation  involved  no  cutting,  no  chloroform  was 
used.  The  patient’s  respiration  speedily  became  stertorous,  and  he  died  in  a few 
minutes. 

Case  X. — In  1853,  Dr.  Richard  Mackenzie  Avas  called  to  see  a patient  aaJio  had 
shortly  before  fallen  and  fractured  the  radius.  After  examining  the  case.  Dr. 
Mackenzie  felt  his  pocket  for  his  chloroform-bottle,  but  found  he  had  it  not  AA’ith 
him.  Anxious  not  to  lose  time  by  sending  for  it,  he  fortliAvith  adjusted  the  dis- 
placed ends  of  the  bone,  and  applied  splints  and  a bandage.  A fcAV  minutes  after 
leaving  the  patient’s  house.  Dr.  Mackenzie  Avas  suddenly  recalled,  and  found  the 
patient  dead. 

If,  in  tlie  preceding  cases,  chloroform  had  happened  to  be  em- 
ployed, the  fatal  results  Avould  naturally  by  most  minds  have  been 
attributed  to  the  anaesthetic,  and  not  to  the  operation  or  the  condition 


DEATHS  FROM  CHLOROFORM. 


153 


of  mind  or  body  connected  with  the  operation.  Such  cases,  how- 
ever, teach  us  at  least  that  caution  is  required  in  our  reasoning  and 
inferences,  seeing  death  may  occur,  and  has  occurred,  in  operations 
without  chloroform,  and  with  phenomena  quite  similar  to  those 
ascribed  to  the  action  of  chloroform.  Most  of  the  stronger  drugs 
in  the  pharmacopoeia — as  opium,  elaterium,  antimony,  mercury,  etc. — 
are,  j)roportionally  to  the  number  of  cases  in  which  they  are  used  in 
full  doses,  as  fatal  as,  or  more  fatal  than,  chloroform,  but  they  are 
not  so  sudden,  and  hence  not  so  terribly  appalling  in  their  dangerous 
and  fatal  effects.  The  number,  for  example,  of  lives  lost  yearly  by 
the  poisonous  effects  of  opium,  etc.,  is  much  greater  than  that  lost 
by  chloroform.^  At  our  different  drug-manufactories  in  Edinburgh 
we  have  upwards  of  two  million  doses  of  chloroform  manufactured 
annually,  yet  how  rarely  does  a fatal  result  follow  its  use ! Is  there 
any  other  common  or  potent  drug  which  could  be  given  in  full 
doses  in  two  millions  of  instances  per  annum  with  greater  impunity? 

^ In  1840,  out  of  every  1,000,000  living  in  England  and  Wales  24  were 
poisoned  by  opium  and  22  by  other  medicines  improperly  given  to  children  below 
the  age  of  five  years. — See  Seventh  Annual  Report  of  the  Registrar- General , p.  82. 
In  England  and  AVales,  in  the  five  years  from  1863-67  there  were  poisoned  by  pre- 
parations of  opium  632  individuals  ; by  salts  of  lead,  242  ; by  overdoses  of 
medicine,  52  ; by  strychnine,  41,  etc.  There  were  droAvned  during  the  same 
period,  while  bathing,  707  persons,  while  sliding  or  skating,  116  ; burned  to 
death  by  clothes  taking  fire,  2194  ; killed  by  falls  in  walking,  194  ; suffocated  by 
bedclothes,  2332  children;  suffocated  by  overlaying,  682  ; died  from  “naA^el 
hemorrliage,”  572,  etc. — See  Thirtieth  Report  of  the  Registrar- General,  pp.  176-8. 


PAET  III. 


THE  NATUEE  AND  POWEE  OF  VAEIOUS 
ANESTHETIC  AGENTS. 

♦ 

CHAPTEE  1. 

GENERAL  CONSIDERATIONS. 

Wliat  are  Anaesthetics  ? — The  word  Anaesthetics  is  employed  to 
designate  a series  of  vapours  or  gases,  which,  when  inhaled,  produce, 
with  more  or  less  rapidity,  the  anaesthesia  or  insensibility  to  pain, 
which  is  required  for  the  practice  of  midwifery  and  surgery. 

They  vary  greatly  in  external  characters  and  in  chemical  compo- 
sition, as  the  following  table  will  show  : — 


Table  op  the  Chief  Anesthetising  Agents. 


Substances. 

Chemical 

Formula. 

State  at 
common 
Temperature. 

Specific 
Gravity  of 
Liquid. 

Specific 
Gravity  of 
Vapour 
or  Gas. 

Boiling 

Point. 

Nitrous  Oxide  . , 

NgO 

gas 

1-525 

Cliloroform 

CHCI3 

liquid 

1-497 

4-2 

142^ 

Sulphuric  Ether  , 

C4H10O 

liquid 

•7365 

2-586 

94-8° 

Nitric  Ether 

C0H5NO3 

liquid 

1-112 

0 

GO 

Nitrous  Ether  , • 

C3H5NO2 

liquid 

•947 

2-627 

61° 

Alcohol  . . . 

C,B,0 

liquid 

•815 

1-6133 

173° 

Aldehyde 

C2H4O 

liquid 

•8009 

1-532 

67-8° 

Dutch  Liquid  . 

C2H4CI2 

liquid 

1-280 

3-450 

184° 

Bisulphide  of  Carbon  . 

CS2 

liquid 

1-272 

Aniylene  . 

C5H10 

liquid 

•659 

2-45 

102° 

Hydride  of  Amyl 

C5H1.2 

liquid 

•638 

2-5 

86° 

Chloride  of  Amyl 

CsHnCl 

liquid 

215° 

Benzina  Benzoli 

CeHe 

liquid 

•85 

2-77 

177° 

Propyl 

CeHn 

1 

GENERAL  CONSIDERATIONS. 


155 


Various  theories  have  been  advanced  at  difierent  times,  trying 
to  attribute  the  power  of  producing  the  peculiar  action  manifested 
by  this  class  of  bodies  to  one  or  more  of  their  constituent  elements. 
The  one  which  has  met  with  most  favour  is  that  in  which  this 
power  is  said  to  be  resident  in  the  carbon,  from  which,  it  is  main- 
tained, all  these  agents  derive  their  anaesthetising  virtues,  more  or 
less  modified  by  the  other  elements  with  which  the  carbon  is  asso- 
ciated. There  is  one  insuperable  objection,  however,  to  this  view, 
for  the  experiments  of  Davy  and  Wells  have  shown  that  nitrous 
oxide  gas  is  an  anaesthetic  of  considerable  power,  and  yet  it  contains 
no  carbon  at  all. 

So  also  with  all  the  other  theories,  none  of  which  are  successful 
in  tracing  the  peculiar  action  of  this  class  of  bodies  to  any  particular 
element. 

How  do  Ancesthetics  produce  their  peculiar  effect  ? — On  this  point 
we  must  at  once  admit  our  complete  ignorance,  for  no  one  has  yet 
satisfactorily  demonstrated  the  manner  in  which  they  do  so. 

Some  suppose  that  they  poison  the  blood,  as  occurs  in  uraemia, 
and  that  so  the  coma  is  induced.  This  is  not  probable,  how- 
ever, for  we  could  hardly  suppose  that  the  effects  would  come  on 
so  rapidly,  or  pass  away  so  quickly,  if  such  were  the  case.  Dr. 
Murphy  holds  the  following  view.  He  thinks  that  the  chloroform, 
not  being  soluble  in  the  blood,  travels  through  the  circulation  un- 
changed. This  free  chloroform,  he  says,  exerts  a great  affinity  for 
oxygen,  so  as  to  prevent  the  usual  affinities  taking  place.  Carbonic 
acid  is  not,  therefore,  formed  in  the  same  proportion,  so  that  carbon 
is  not  sufficiently  removed  from  the  tissues,  and  accordingly  he 
supposes  the  anaesthetic  influence  is  kept  up.  He  supports  this 
view  by  the  fact,  that  intense  cold  acts  as  an  anaesthetic,  and  that 
this  is  owing  to  cold  diminishing  the  amount  of  carbonic  acid. 

The  rapidity  of  action  of  anaesthetics  is  to  be  explained  by  the 
mode  in  which  they  are  introduced  into  the  system ; for  it  is  a well- 
known  fact  that  medicines  act  much  more  rapidly  if  inhaled  in  the 
form  of  vapour  or  gas,  than  if  introduced  into  the  stomach,  or  taken 
in  any  other  way.  The  vapour  is  at  once  applied  to  the  whole 
surface  of  the  pulmonary  mucous  membrane  (which  is  very  large, 
being  calculated  by  Dr.  Keid  to  have  fifty  times  the  superficies  of 
the  cutaneous  surface),  immediately  beneath  which  an  infinite  num- 
ber of  minute  capillaries  are  distributed,  so  that  the  vapour  almost 
instantaneously  gets  entrance  into  the  blood.  It  is  then  hurried 
through  the  circulation,  and,  in  the  space  of  one  or  two  minutes, 


156 


NATURE  AND  POWER  OF  ANAESTHETIC  AGENTS. 


comes  in  contact  with  the  lining  membrane  of  the  entire  vascular 
system,  which  is  many  hundred  times  greater  in  extent  than  the 
cutaneous  surface. 

Under  those  circumstances,  can  we  wonder  that  its  action,  in 
whatever  way  it  may  subsequently  be  brought  about,  should  be 
so  rapid  1 A great  revolution  may  occur  some  day  in  medicine,  so 
that  it  may  become  a more  general  practice  to  administer  remedies 
by  the  way  of  inhalation,  and  thus  insure  a far  more  rapid  induction 
of  their  physiological  effects.  What  an  advantage  it  would  be,  for 
instance,  if  we  were  able  to  produce  mercurialism  in  a few  hours, 
instead  of  requiring  at  least  two  or  three  days  to  affect  it  ! 

The  rapid  disappearance  of  the  effects  of  the  chloroform  is, 
however,  quite  as  remarkable  as  the  rapidity  with  which  they  are  pro- 
duced. Sulphuric  ether  and  most  other  anaesthetics  are  easily  known 
to  pass  off,  in  a great  measure  at  least,  by  the  lungs,  as  the  breath 
of  the  patient  smells  of  them  for  some  days  afterwards. 

This  is  not  observed  so  easily  with  chloroform,  but  it,  too,  pro- 
bably passes  off  in  the  same  manner.  Dr.  Snow  says  that  the 
chloroform  cannot  be  detected  in  the  breath  by  the  sense  of  smell, 
after  the  lungs  have  been  emptied  by  two  or  three  expirations  of 
the  vapour  they  contained  when  the  inhalation  was  stopped.  He 
has  detected  it,  however,  in  the  breath  by  chemical  tests,  even  after 
the  return  of  consciousness.  The  chloroform  may  pass  off  by  the 
kidney  also,  but,  if  so,  it  is  only  in  very  minute  quantity. 


CHLOKOrORM. 


157 


CHAPTER  IL 

CHLOROFORM. 

**  I esteem  it  the  office  of  a physician,  not  only  to  restore  health,  hut  to 
mitigate  pain  and  dolours.” — Bacon. 

Edinburgh,  November  1847. 

From  the  time  at  which  I first  saw  ether-inhalation  successfully 
practised  in  January  last,  I have  had  the  conviction  impressed  upon 
my  mind,  that  we  should  ultimately  find  that  other  therapeutic 
agents  were  capable  of  being  introduced  with  equal  rapidity  and 
success  into  the  system,  through  the  same  extensive  and  powerful 
channel  of  pulmonary  absorption.  In  some  observations,  which  I 
wrote  and  published  in  March  last,  relative  to  the  inhalation  of 
sulphuric  ether  in  midwifery,  I stated  that,  in  several  obstetric  cases, 
I had  used  ergot  of  rye  in  this  way,  along  with  ether.’ 

With  various  professional  friends,  more  conversant  with  chemistry 
than  I am,  I have,  since  that  time,  taken  opportunities  of  talking 
over  the  idea  which  I entertained  of  the  probable  existence  or  dis- 
covery of  new  therapeutic  agents,  capable  of  being  introduced  into 
the  system  by  respiration,  and  the  possibility  of  producing  for  in- 
halation vaporisable  or  volatile  preparations  of  some  of  our  more 
active  and  old-established  medicines  : and  I have  had,  during  the 
summer  and  autunin,  ethereal  tinctures,  etc.,  of  several  potent  drugs, 
manufactured  for  me,  for  experiment,  by  Messrs.  Duncan,  Flockhart, 
and  Companjq  the  excellent  chemists  and  druggists  of  this  city. 

Latterly,  in  order  to  avoid,  if  possible,  some  of  the  inconveniences 
and  objections  pertaining  to  sulphuric  ether — (particularly  its  dis- 
agreeable and  very  persistent  smell,  its  occasional  tendency  to 
irritation  of  the  bronchi  during  its  first  inspirations,  and  the  large 
quantity  of  it  occasionally  required  to  be  used,  more  especially  in 
protracted  cases  of  labour) — I have  tried  upon  myself  and  others 
the  inhalation  of  other  different  volatile  fluids,  with  the  hope  that 
some  one  of  them  might  be  found  to  possess  the  advantages  of  ether 
^ See  Part  V.  Chap.  I. 


15S 


NATURE  AND  POWER  OF  ANAESTHETIC  AGENTS. 


without  its  disadvantages.  For  this  purpose,  I selected  for  experi- 
ment, and  have  inhaled,  several  chemical  liquids  of  a more  fragrant 
or  agreeable  odour,  such  as  the  chloride  of  hydrocarbon  (or  Dutch 
liquid),  acetone,  nitrate  of  oxide  of  ethyle  (nitric  ether),  benzin,  the 
vapour  of  iodoform,  etc.*  I have  found,  however,  one  infinitely 
more  efficacious  than  any  of  the  others,  viz..  Chloroform,  or  the 
Perchloride  of  Formyle,  and  I am  enabled  to  speak  most  confidently 
of  its  superior  anaesthetic  properties,  having  now  tried  it  upon  up- 
wards of  thirty  individuals.  The  liquid  I have  used  has  been 
manufactured  for  me  by  Mr.  Hunter,  in  the  laboratory  of  Messrs. 
Duncan,  Flockhart,  and  Company. 

As  an  inhaled  anaesthetic  agent,  chloroform  possesses  over  sul- 
phuric ether  the  following  advantages  : — 

1.  A greatly  less  quantity  of  chloroform  than  of  ether  is  requisite 
to  produce  the  anaesthetic  effect ; usually  from  a hundred  to  a hun- 
dred and  twenty  drops  of  chloroform  only  being  sufficient ; and 
with  some  patients  much  less.  I have  seen  a strong  person  ren- 
dered completely  insensible  by  six  or  seven  inspirations  of  thirty 
drops  of  the  liquid. 

2.  Its  action  is  much  more  rapid  and  complete,  and  generally 
more  persistent.  I have  almost  always  seen  from  ten  to  twenty 
full  inspirations  suffice.  Hence  the  time  of  the  surgeon  is  saved ; 
and  that  preliminary  stage  of  excitement,  which  pertains  to  all 
narcotising  agents,  being  curtailed,  or  indeed  practically  abolished, 
the  patient  has  not  the  same  degree  of  tendency  to  exhilaration  and 
talking.^ 

^ In  talking  over,  with  different  chemists,  what  fluids  might  he  sufficiently 
volatile  to  be  respirable,  and  hence  deserving  of  being  experimented  upon,  Mr. 
Waldie  first  named  to  me  the  perchloride  of  formyle,  as  worthy,  among  others,  of 
a trial ; — Dr.  Gregory  suggested  a trial  of  the  chloride  of  hydrocarbon,  etc.  I 
have  been  deeply  indebted  to  Dr.  Gregory  and  Dr.  Anderson,  for  their  kindness 
in  furnishing  me  with  the  requisite  chemical  agents  for  these  experiments  ; — and 
also  to  my  assistants.  Dr.  Keith  and  Dr.  Duncan,  for  the  great  and  hearty  zeal 
wdth  which  they  have  constantly  aided  me  in  conducting  the  inquiry. 

2 In  practice  I have  found  that  any  such  tendency,  even  with  ether,  is 
avoided  by — 1st,  giving  the  patient  from  the  first  a large  and.  overwhelming  dose 
of  the  vapour,  and  2dly,  by  keeping  him  perfectly  quiet  and  still,  and  preventing 
all  noise  and  talking  around  him.  I have  elsewhere  insisted  on  the  importance 
of  these  points.  (See  the  numbers  of  the  Monthly  Journal  of  Medical  Science  for 
March  1847,  p.  726,  and  for  September,  p.  154.)  In  the  ]»aper  last  referred  to,  I 
took  occasion,  when  discussing  the  conditions  requisite  for  insuring  successful 
etherisation,  to  observe,  “First,  The  patient  ought  to  be  left,  as  far  as  possible,  in 
a state  of  absolute  quietude  and  freedom  from  mental  excitement,  botli  during  the 
induction  of  etherisation,  and  during  his  recovery  from  it.  All  talking  and  all 


CHLOROFORM. 


159 


3.  Most  of  those  who  know  from  previous  experience  the  sensa- 
tions produced  by  ether-inhalation,  and  who  have  subsequently 
breathed  chloroform,  have  strongly  declared  the  inhalation  and 
influence  of  chloroform  to  be  far  more  agreeable  and  pleasant  than 
those  of  ether. 

4.  I believe  that,  considering  the  small  quantity  requisite,  as 
compared  with  ether,  the  use  of  chloroform  will  be  less  expensive 
than  that  of  ether ; more  especially,  as  there  is  every  prospect  that 
the  means  of  forming  it  may  be  simplified  and  cheapened. 

5.  Its  perfume  is  not  unpleasant,  but  the  reverse  ; and  the 
odour  of  it  does  not  remain  for  any  length  of  time,  obstinately 
attached  to  the  clothes  of  the  attendant — or  exhaling  in  a disagree- 
able form  from  the  lungs  of  the  patient,  as  so  generally  happens 
with  sulphuric  ether. 

6.  Being  required  in  much  less  quantity,  it  is  much  more  port- 
able and  transmissible  than  sulphuric  ether. 

7.  No  special  kind  of  inhaler  or  instrument  is  necessary  for  its 
exhibition.  A little  of  the  liquid  diffused  upon  the  interior  of  a 
hollow-shaped  sponge,  or  a pocket-handkerchief,  or  a piece  of  linen 
or  paper,  and  held  over  the  mouth  and  nostrils,  so  as  to  be  fully 
inhaled,  generally  suffices  in  about  a minute  or  two  to  produce  the 
desired  effect.* 

questioning  should  be  strictly  prohibited.  In  this  way  an}’-  tendency  to  excite- 
ment is  eschewed,  and  the  proper  effect  of  the  ether-inhalation  more  speedily  and 
certainly  induced.  And,  Secondly,  with  the  same  view,  the  primary  stage  of 
exhilaration  should  be  entirely  avoided,  or  at  least  reduced  to  the  shortest  possible 
limit,  by  impregnating  the  respired  air  as  fully  with  the  ether  A'apour  as  the 
patient  can  bear,  and  by  allowing  it  to  pass  into  the  lungs  both  by  the  mouth 
and  nostrils,  so  as  rapidly  and  at  once  to  superinduce  its  complete  and  anesthetic 
effect  j -^  * * * a very  common  but  certainly  a very  unpardonable  error 

being  to  exhibit  an  imperfect  and  exciting,  instead  of  a perfect  and  narcotising 
dose  of  the  vapour.  Many  of  the  alleged  failures  and  misadventures  are  doubtless 
entirely  attributable  to  the  neglect  of  this  simple  rule  ; — not  the  principle  of 
etherisation,  but  the  mode  of  putting  it  in  practice  being  altogether  to  blame. 
But,  Thirdly,  whatever  means  or  mode  of  etherisation  is  adopted,  the  most  im- 
portant of  the  conditions  required  for  procuring  a satisfactory  and  successful 
result  from  its  employment  in  surgery,  consists  in  obstinately  determining  to 
avoid  the  commencement  of  the  operation  itself,  and  never  venturing  to  apply 
the  knife,  until  the  patient  is  under  the  full  influence  of  the  ether  vapour,  and 
thoroughly  and  induhitahly  soporised  hy  it”  In  fulfilling  all  these  indications, 
the  employment  of  chloroform  evidently  offers  great  and  decided  advantages,  in 
facility  and  efficiency,  over  the  employment  of  ether. 

^ When  used  for  surgical  purposes,  perhaps  it*  will  be  found  to  be  most  easily 
given  upon  a handkerchief,  gathered  up  into  a cup-like  form  in  the  hand  of  the 
exhibitor,  and  with  the  open  end  of  the  cup  placed  over  the  nose  and  mouth  of 


160 


NATURE  AND  POWER  OF  ANAESTHETIC  AGENTS. 


It  is  perhaps  not  unworthy  of  remark,  that  when  Soubeiran, 
Liebig,  and  Dumas,  engaged  a few  years  back  in  these  inquiries 
and  experiments  by  whiclu  the  formation  and  composition  of 
chloroform  was  first  discovered,  their  sole  and  only  object  was 
the  investigation  of  a point  in  philosophical  chemistry.  They 
laboured  for  the  pure  love  and  extension  of  knowledge.  They 
had  no  idea  that  the  substance  to  which  they  called  the  attention 
of  their  chemical  brethren  could  or  would  be  turned  to  any 
jpractical  purpose,  or  that  it  possessed  any  physiological  or  thera- 
peutic effects  upon  the  animal  economy.  I mention  this  to  show 
that  the  cui  bono  argument  against  philosophical  investigations,  on 
the  ground  that  there  may  be  at  first  no  apparent  practical  benefit 
to  be  derived  from  them,  has  been  amply  refuted  in  this,  as  it  has 
been  in  many  other  instances.  For  I feel  assured,  that  the  use  of 
chloroform  wdll  soon  entirely  supersede  the  use  of  ether ; and,  from 
the  facility  and  rapidity  of  its  exhibition,  it  will  be  employed  as  an 
anaesthetic  agent  in  many  cases,  and  under  many  circumstances,  in 
which  ether  would  never  have  been  had  recourse  to.  Here  then 
we  have  a substance  which,  in  the  first  instance,  was  merely  inter- 
esting as  a matter  of  scientific  curiosity  and  research,  becoming 
rapidly  an  object  of  intense  importance,  as  an  agent  by  which 
human  suffering  and  agony  may  be  annulled  and  abolished,  under 
some  of  the  most  trying  circumstances  in  which  human  nature  is 
ever  placed. 

Edinburgh,  December  1847. 

At  the  first  winter  meeting  of  the  Edinburgh  Medico-Chirurgical 
Society,  10th  November  1847,  1 directed  the  attention  of  the  mem- 
bers to  a new  respirable  anaesthetic  agent  which  I had  discovered 
a short  time  previously — viz..  Chloroform,  Chloroformyle,  or  Per- 
chloride  of  Formyle.  In  this  chapter  I shall  state  briefly  some  of  the 
principal  facts  pertaining  to  its  history,  composition,  effects,  etc. 

Chemical  History  and  Comjmsition. — Chloroform  was  discovered  at 
nearly  the  same  time  by  Soubeiran  (1831),  and  Liebig  (1832).  Its 
chemical  composition  was  first  ascertained  by  Dinnas  and  Peligot 

the  patient.  For  the  first  inspiration  or  two,  it  should  he  lield  at  the  distance  of 
half-an-inch  or  so  from  the  face,  and  then  more  and  more  closely  applied  to  it. 
To  insure  a rapid  and  perfect  antesthetic  effect — more  especially  where  the  opera- 
tion is  to  he  severe — one  or  two  teaspoonfuls  of  the  chloroform  should  be  at  once 
placed  upon  the  hollow  of  the  handkerchief,  and  immediately  held  to  the  face  of 
the  patient.  Generally  a snoring  sleep  speedily  supervenes  ; and  when  it  does  so, 
it  is  a perfect  test  of  the  superinduction  of  complete  insensibility.  But  a patient 
may  be  quite  anaesthetic  without  this  symptom  supervening. 


CHLOROFOKM. 


161 


(1835).  It  consists  of  2 atoms  of  carbon,  1 of  hydrogen,  and  3 of 
chlorine ; or,  to  express  it  otherwise,  of  1 atom  of  formyle,  and  3 of 
chlorine.  Hence  its  chemical  formula  is  CgHCl  ; or  FoCl  .* 

Modes  of  Preparation. — It  may  he  obtained  by  various  processes. 
1.  By  the  distillation  of  a mixture  of  diluted  spirit,  pyroxylic  or 
wood  spirit,  or  acetone,  and  chloride  of  lime  (bleaching  powder) ; 
or,  2.  By  making  milk  of  lime,  or  an  aqueous  solution  of  caustic 
alkali,  act  upon  cldoral ; 3.  By  leading  a stream  of  chlorine  gas  into 
a solution  of  caustic  potass  in  spirit  of  wine,  etc. 

Physical  and  Chemical  Properties. — It  is  a clear  limpid  liquid,  as 
heavy  as  1*480;  not  inflammable  ; very  volatile  ; and  boils  at  141°. 
It  has  a fragrant,  fruit-like  odour ; and  a sweet  saccharine  taste. 

Therapeutic  History. — It  has  been  used  internally.  Guillot  em- 
ployed it  in  asthma,  diluted  with  water  one  hundred  times  (1844). 
My  friend.  Dr.  Formby  of  Liverpool,  told  me,  about  two  years  ago, 
that  he  used  it  often  in  a diluted  form  as  a diffusible  stimulant ; 
and  I have,  since  that  period,  frequently  prescribed  it  instead  of 
valerian,  camphor,  etc.^  But  I am  not  aware  that  any  person  has 
used  chloroform  by  inhalation,  or  discovered  its  remarkable 
anaesthetic  properties,  till  the  date  of  my  own  experiments. 

Physiological  Effects. — After  the  first  two  or  three  full  inspirations, 
a feeling  of  warmth  and  excitation,  radiating  from  the  chest  to  the 
extremities ; followed  by  whirring  noises  in  the  ears ; a sensation 
of  vibratory  thrilling  and  benumbing  throughout  the  body ; with, 
betimes,  rapid  loss  of  sensation  and  of  motion,  and  at  last  of  con- 
sciousness. Often  before  total  unconsciousness  supervenes,  the 
patient,  guided  by  instinct  rather  than  by  volition  and  reason, 
makes  an  effort  to  get  rid  of  the  inhaling  vapour  and  handkerchief, 
as  if  it  interfered  with  free  respiration.  This  temporary  effort  must 
be  resisted  by  the  exhibitor.  During  the  full  anaesthetic  sleep  pro- 
duced by  chloroform,  sometimes  no  mental  action  goes  on,  or  at 
least  is  remembered ; in  many  others,  the  mind  is  active  as  in 
dreams.  The  respiration  is  usually  at  first  soporose ; the  pupil 
sometimes  natural,  in  others  slightly  contracted,  in  others,  dilated 
The  pulse  is  usually  quickened  ten  or  twenty  beats  at  first,  but 
afterwards  falls  to  its  normal  rate,  and  if  the  vapour  is  exhibited 

^ CHClg,  by  present  notation.  [Ed.]  * 

2 Since  first  publishing  on  the  subject  of  chloroform,  Dr.  Glover  of  Newcastle 
has  pointed  out  to  me,  that,  in  an  essay  on  Bromine,  in  the  15  2d  number  of  the 
Edinburgh  Medical  and  Surgical  Journal,  he  mentions  having  poisoned  several 
animals  with  chloroform,  by  injecting  it  into  their  blood-vessels,  stomach,  and  the 
cavity  of  the  peritoneum,  and  has  investigated  its  physiological  mode  of  action. 


162 


NATURE  AND  POWER  OF  ANAESTHETIC  AGENTS. 


very  long  in  very  powerful  doses,  it  comes  down  more  and  more 
below  the  natural  standard ; muscles  of  voluntary  motion  in 
general  relaxed  ; more  rarely  cataleptic  ; still  more  rarely  clonically 
contracted,  as  happens  also  occasionally  with  ether. 

In  small  doses,  given  slowly,  its  effects  are  exhilarating,  and 
exactly  like  those  generally  following  the  inhalation  of  nitrous 
oxide  gas.  Of  course,  when  exhibited  in  this  way,  the  patient  is  in 
a state  of  excitement  quite  unfit  for  a surgical  operation.  When 
given  for  surgical  operations,  it  should  be  exhibited  rapidly  in  large 
doses,  and  the  patient  sent  over  into  a deep  soporose  or  stertorous 
sleep  before  the  incisions  are  begun.* 

Uses  in  Surgery. — 1.  To  relax  the  muscles  in  reducing  disloca- 
tions, etc. ; 2.  To  avert  the  sufferings  attendant  on  deep  probing, 
and  other  painful  but  necessary  modes  of  diagnostic  examination 
and  dressing ; and  3,  and  principally.  To  annul  the  pain  of  opera- 
tions by  the  caustic,  ligature,  or  knife. 

Uses  in  Midivifery. — To  diminish  and  annul  the  physical  pains 
attendant  on  labour,  and  more  especially  those  which  accompany 
the  passage  of  the  child’s  head  through  the  pelvic  cavity  and  outlet 
■ — (the  second  stage  of  Denman). 

Uses  in  Medicine. — 1.  As  an  antispasmodic  ; as  in  asthma,  laryn- 
gismus, tetanus,  and  other  spasmodic  diseases,  etc.,‘^  I have  used 

^ I believe  all  the  reputed  failures  and  misadventures  are  attributable  to  two 
causes — viz.,  1.  Using  an  impure  and  imperfect  variety  of  chloroform  ; and  2.  Not 
giving  it  in  sufficiently  large  and  rapid  doses. 

^ In  various  trials  at  Morningside,  at  which  Dr.  Christison,  Dr.  Skae,  and  Dr. 
Wingett  were  present,  Dr.  S.  had  sent  violent  patients  over  into  a soporose  sleep 
in  a minute  or  less.  a\s  to  what  its  therapeutic  effects,  if  any,  might  be  in 
insanity,  Ave  had,  he  believed,  no  power  yet  of  judging.  It  could  not  be  expected 
to  be  of  any  marked  service — at  least  in  any  short  time — in  such  chronic  cases,  as 
it  had  been  tried.  But  it  had  this  effect : the  patients  could  be  kept  asleep 
under  it  for  a long  series  of  hours.  In  this  way,  it  had  already  apparently  cured 
some  cases  of  delirium  tremens,  and,  he  believed,  also  of  puerperal  insanity,  and 
might  yet  be  found  useful  in  other  forms  of  acute  mania.  At  all  events,  it  was  a 
means  of  restraining  a furious  maniac  ; as  powerful,  and,  perhaps,  it  would  be 
found  far  more  safe  tlian  a strait-jacket  or  the  grasp  of  a number  of  keepers.  Once 
set  a patient  over  (and  that  was  the  Avork  of  a minute),  and  a nurse  Avith  a pocket- 
handkerchief  and  some  chloroform  might  keep  him  under  perfect  and  complete 
restraint.  Nor  need  he  add  hoAV  useful  the  same  means  might  be  in  enabling  a 
riotous  and  resisting  patient  to  be  removed  to  an  asylum,  or  from  one  place  to 
another.  It  AA^ould  be  tedious  to  discuss  all  the  other  diseases  in  AA'hich  it  had 
already  been  tried.  Dr.  S.  Avas  most  anxious  to  observe  its  effects  in  acute  local 
inflammations,  but  he  had,  as  yet,  fcAV  opportunities  of  doing  so.  He  mentioned 
a case  he  had  seen  Avith  Dr.  Dease  (apparently  an  extra-uterine  conception  bursting 
into  the  abdomen),  and  where  the  accompanying  severe  abdominal  pain,  and  its 


CHLOROFORM. 


163 


successfully  the  inhalation  of  ether  to  arrest  the  paroxysms  of 
hooping-cough,  dysmenorrhoea,  colic,  and  the  pains  attendant  on  the 
passage  of  biliary  calculi.  In  a case  of  the  most  severe,  at  the  same 
time  painful,  spasmodic  twisting  and  convulsions  of  the  extremities 
attending  a second  attack  of  chorea,  I allowed  the  patient  ether- 
inhalation  ; and  sometimes  she  lay  under  its  influence  for  hours, 
with  relief  while  its  action  lasted,  but  generally  without  sleep. 
Latterly  the  chloroform  has  both  relieved  the  spasms  and  their 
attendant  pain,  and  procured  sleep.  2.  As  an  anodijne  or  narcotic. 
In  neuralgia,  I have  seen  chloroform  stop  the  fit  at  once ; in  two 
other  cases  the  pain  remained  absent  only  while  the  chloroform 
acted.  A patient  suffering  under  severe  delirium  tremens  had  re- 
mained awake  for  about  seventy  hours ; a half-ounce  of  laudanum, 
given  at  a single  dose,  failed  to  produce  rest ; ten  hours  afterwards, 
the  inhalation  of  chloroform  was  immediately  followed  by  several 
hours  of  critical  sleep.  What  cases  of  insanity  would  it  benefit  1 
I have  exhibited  it  in  full  doses  in  some  cases  of  dementia,  combined 
with  excitement  and  wakefulness.  They  were  all  asleep  in  about  a 
minute, — and  remained  so  for  some  time.  In  nothing  does  chloro- 
form differ  from  ether  more  than  in  its  soporific  effects — when  given 
in  full  doses,  and  continued  for  some  time.  3.  In  small  doses  as  a 
diffusihle  stimulant ; to  arrest  the  first  commencement  of  ague,  ephe- 
mera, etc. ; in  hysteria,  etc.  Perhaps  it  may  be  used  by  inhalation 
in  small  quantities  when  the  stomach  will  not  bear  wine  or  other 
stimulants ; in  severe  vomiting,  fevers,  etc.  I have  seen  its  inhala- 
tion at  once  dispel  a sick  headache.  4.  As  a contra-stimulant^  in 
inflammatory  diseases,  especially  those  of  a painful  character'?'? 
Acute  rheumatism,  etc.  ? ? 

Cautions. — The  liquid  used  should  be  sufficiently  strong.  Its 
proper  sp.  gr.  is  (as  I have  said)  I *480.  I have  seen  some  specimens 
perfectly  unfit  for  use  from  their  weakness ; others  perfectly  unfit 
from  their  want  of  purity,  for  although  of  the  proper  specific  gravity, 
they  contained  free  chlorine,  irritating  the  throat,  and  making  the 
patient  cough.  It  is  certainly  far  too  powerful  an  agent  to  be 

dreadfully  depressing  effects,  were  kept  at  bay  by  the  anaesthetic  and  contra- 
stimulant  effects  of  the  chloroform.  He  mentioned  a case  of  extremely  severe 
cholera,  where,  after  all  things  had  failed,  and  the  patient  was  apparently  sinking, 
the  inhalation  of  chloroform  had  induced  sleep — dispelled  the  spasms  and  vomit- 
ing— and  restored  the  patient.— (From  the  Discussion  at  the  Medico-Chirurgical 
Society  of  Edinburgh,  on  December  15,  1847.  See  Monthly  Joimuil  of  Medical 
Science  for  January  1848.)  ^ See  also  p.  189. 


164 


NATURE  AND  POWER  OF  ANAESTHETIC  AGENTS. 


intrusted  to  nurses  or  unprofessional  individuals.  I have  given  it, 
up  to  this  date,  to  above  eighty  persons,  without  the  slightest  bad 
result  of  any  kind  whatever  in  any  one  of  them.  The  power,  how- 
ever, which  we  have  with  it,  of  bringing  down  the  pulse,  etc.,  shows 
that,  if  exhibited  in  too  strong  a dose,  given  uninterruptedly  for  too 
great  a length  of  time,  .it  would  doubtless  produce  serious  conse- 
quences, and  even  death.  But,  certainly,  all  its  full  anaesthetic  and 
other  influences  may  be  perfectly  obtained  without  allowing  it  to 
produce  such  depression  as  would  be  in  any  degree  dangerous.  I 
have,  in  obstetric  cases,  kept  patients  under  its  influence  for  several 
consecutive  hours,  without  any  resulting  harm  of  any  kind  to  either 
mother  or  child, — renewing  its  application  from  time  to  time  after 
the  first  full  dose.  Like  many  other  agents,  it  may  be  powerful  for 
evil  as  well  as  for  good.  I believe  its  great  potency  will  be  one  great 
safeguard  against  its  abuse. 

Its  influence  upon  the  blood,  etc.,  the  counter-indications  to  its 
use,  etc.  etc.,  remain  still  to  be  ascertained. 


CHLOlilDE  OF  HYDROCARBON. 


165 


CHAPTEE  III. 

CHLORIDE  OF  HYDROCARBON,  NITRATE  OF  ETHYLE,  BENZIN, 
ALDEHYDE,  AND  BISULPHURET  OF  CARBON. 

Edinburgh,  April  1848. 

During  the  last  few  months  two  or  three  different  substances  have 
been  brought  forward  as  anjesthetic  agents  ; but  our  medical  journals 
have  afforded  little  or  no  detailed  notice  of  their  effects.  The  few 
following  notes,  however  imperfect,  may  not  therefore  be  uninterest- 
ing ; more  particularly  as  they  are  the  result  of  direct  experiments 
upon  myself  and  others  with  the  agents  in  question.  In  most  of 
these  experiments  I had  the  kind  and  able  assistance  of  Dr.  Keith 
and  Dr.  Duncan. 

When  first  publishing,  in  November  1847,  upon  the  anaesthetic 
properties  of  chloroform,  I stated  that  “ in  making  a variety  of 
experiments  upon  the  inhalation  of  different  volatile  chemical  liquids, 
I have,  in  addition  to  perchloride  of  formyle,  breathed  chloride  of 
hydrocarbon,  acetone,  nitrate  of  oxide  of  ethyle,  benzin,  the  vapour 
of  iodoform,  etc.  I may  probably,”  I added,  “ take  another  oppor- 
tunity of  describing  the  result.” 

Three  of  the  substances  which  I named  in  the  preceding  list, 
produce,  when  inhaled,  a state  of  anaesthetic  insensibility  — viz. 
chloride  of  hydrocarbon,  nitrate  of  oxide  of  ethyle,  and  benzin. 

CHLORIDE  OF  HYDROCARBON. 

Chloride  of  Hydrocarbon,  or  Dutch  liquid,  as  it  is  often  termed,  in 
consequence  of  it  being  first  discovered  by  the  Dutch  chemists  of  the 
last  century,  is  one  of  the  various  fluids  to  which  the  name  of  Chloric 
Ether  was  for  some  time  given. 

When  equal  parts  of  olefiant  gas  and  chlorine  are  mixed  together, 
the  two  gases  rapidly  disappear,  and  produce  a colourless  oily  liquid, 
of  a peculiar  sweetish  taste  and  ethereal  odour.  Its  specific  gravity 

^ See  Lancet  for  20th  November  1847,  p.  549. 


1G6 


NATURE  AND  POWER  OF  ANiESTHETIC  AGENTS. 


is  1’247.  It  boils  at  148°.  It  is  composed  of  four  atoms  of 
carbon,  four  of  hydrogen,  and  two  of  chlorine.  Hence  its  formula 
is 

4 4 2 

When  its  vapour  is  inhaled,  the  chloride  of  hydrocarbon  causes 
so  great  irritation  of  the  throat,  that  few  can  persevere  in  breathing 
it  for  such  a length  of  time  as  to  induce  anaesthesia.  I have  latterly, 
however,  seen  it  inhaled  perseveringly  until  this  state,  with  all  its 
usual  phenomena,  followed,  and  without  excitement  of  the  pulse,  or 
subsequent  headache.  When  I myself  attempted  to  inhale  the 
chloride  of  hydrocarbon,  it  produced  an  extreme  degree  of  acrid 
irritation  in  the  throat,  which  did  not  disappear  entirely  for  many 
hours  afterwards. 

NITRATE  OF  ETHYLE. 

When  two  parts  of  alcohol,  and  one  part  of  pure  nitric  acid, 
are  distilled  together,  with  the  addition  of  a small  quantity  of  urea. 
Nitrate  of  Ethyle,  or,  more  properly.  Nitrate  of  Oxide  of  Ethjle^  is  pro- 
duced. It  is  a transparent  colourless  liquid,  with  a sweet  taste,  and 
very  agreeable  odour.  Its  specific  gravity  is  1*112  ; it  boils  at  185°. 
It  is  a compound  of  four  proportions  of  carbon,  five  of  hydrogen,  six 
of  oxygen,  and  one  of  nitrogen ; and  its  formula  is  0,  NO^, 

or  AcO, 

Nitrate  of  ethyle  is  easy  and  pleasant  to  inhale,  and  possesses 
very  rapid  and  powerful  anaesthetic  properties.  A small  quantity, 
such  as  fifty  or  sixty  drops,  when  sprinkled  on  a handkerchief  and 
inhaled,  produces  insensibility  after  a few  inspirations.  But  during 
the  brief  period  which  elapses  before  the  state  of  complete  anaesthesia 
is  induced,  the  sensations  of  noise  and  fulness  in  the  head  are  in 
general  excessive ; and  much  headache  and  giddiness  have  usually 
followed  its  employment,  and  persisted  for  some  time. 

I 

BENZIN. 

Benzin  or  Benzole  was  first  discovered  by  Faraday,  as  one  of  the 
products  in  his  experiments  on  compressing  oil-gas,  and  was  desig- 
nated by  him  Bicarhuret  of  Hydrogen.  Mitscherlich  afterwards 
obtained  it  by  distilling,  at  a high  temperature,  benzoic  acid  with 
an  excess  of  slaked  lime. 

It  is  a clear  colourless  liquid,  of  a peculiar  ethereal  odour ; with 

^ C9H4C]. 2 by  present  notation.  [Ed.I 
2 CX  0,  NO.,  „ „ [Ed.] 


ALDEHYDE. 


167 


a specific  gravity  of  0’85  ; and  boils  at  18G°.  Its  formula  is 

In  my  experiments  with  benzin  I found  it  capable  of  producing 
anaesthesia ; but  the  ringing  and  noises  in  the  head  accompanying 
and  following  its  inhalation  were  so  excessive,  and  almost  intoler- 
able in  the  case  of  myself  and  others,  as  to  seem  to  us  to  render  its 
2:)ractical  apjdications  impossible,  even  had  there  been  no  other 
objections  to  its  use.  Latterly,  Dr.  Snow  has  tried  its  emjdoyment 
upon  some  patients  for  tooth-drawing;  and  in  one  instance  of 
amputation.  In  this  last  case  it  produced  convulsive  tremors.* 

ALDEHYDE. 

Aldehyde,  or  Hydrate  of  Oxide  of  Acetyle,  w^as  first  noticed  by 
Doebereiner  in  distilling  together  suljdiuric  acid,  alcohol,  and  peroxide 
of  manganese  ; but  it  was  left  for  Liebig  to  fix  and  determine  every- 
thing about  its  chemical  nature.  It  is  a colourless  limpid  liquid,  of 
specific  gravity  0’791.  It  is  very  volatile,  boiling  at  72°.  It 
spontaneously  changes  wdien*  long  kept,  and  is  converted  into  two 
substances,  a solid  and  a fluid,  metaldehyde  and  elaldehyde.  Liebig 
found  it  to  be  composed  of  four  atoms  of  carbon,  four  atoms  of 
hydrogen,  and  two  of  oxygen  ; and  its  formula  is 

Professor  Poggiale  of  Paris  has  lately  made  some  experiments 
with  dogs  on  the  inhalation  of  the  vapour  of  aldehyde,  and  from 
these  has  concluded  that  its  ansesthetic  effects  wdll  be  found  more 
prompt  and  energetic  than  those  of  sulphuric  ether  or  chloroform. 
It  certainly  ^^ossesses,  like  some  of  the  2)receding  agents,  well-marked 
anaesthetic  proj^erties  ; but  it  assuredly  will  never  come  into  use,  as 
very  few  will  be  found  capable  of  inhaling  a sufficient  dose  of  its 
vapour.  In  fact,  out  of  five  of  us  that  attempted  to  inhale  aldehyde, 
very  carefully  2)repared  and  i^urified,  four  were  driven  to  suspend  the 
respiration  of  it  in  consequence  of  the  coughing  and  insufferable  feel- 
ings of  dyspnoea  which  it  immediately  induced.  The  sensations  of  diffi- 
cult respiration  and  constriction  in  the  chest  which  the  va2)our  ^wo- 
duced,  resembled  ^^recisely  those  of  a severe  fit  of  spasmodic  asthma. 
In  the  fifth  case,  the  experimentalist,  after  ^lerseveringly  breathing 
the  aldehyde  for  a minute  or  two,  became  entirely  insensible ; the 
state  of  anaesthesia  lasted  for  two  or  three  minutes  ; during  it,  the 
pulse  became  excessively  small  and  feeble.  On  recovering,  the 
bronchial  constriction  and  coughing,  which  had  disappeared  as  the 

CgHg  by  present  notation.  [Ed.]  Lancet  for  12tli  February  1848,  j).  130. 
C2H4O  by  jiresent  notation.  [Ed.  ] 


•67 


168 


NATUKE  AND  POWER  OF  ANESTHETIC  AGENTS. 


anaesthesia  was  induced,  returned  immediately,  and  were  annoying 
for  some  time  after. 


BISULPHURET  OF  CARBON. 

Bisulphiiret  of  Carhon,  or  Alcohol  of  Sulphur  (as  it  was  at  first 
termed),  was  accidentally  discovered  in  1796  by  Lampadius,  when 
experimenting  on  iron  pyrites.  Different  opinions  of  its  compo- 
sition were  held  by  different  chemists  ; but  Berzelius  and  Marcet, 
in  1813,  at  last  fully  confirmed  the  previous  idea  of  Clement  and 
Desormes,  Vauquelin,  etc.,  that  it  consisted  only  of  sulphur  and 
carbon.  It  is  composed  of  two  atoms  of  the  former  to  one  of  the 
latter  ; consequently  its  formula  is  CS^. 

The  most  easy  method  of  procuring  it  is  by  transmitting  the 
vapour  of  sulphur  over  fragments  of  charcoal  heated  to  redness  in  a 
closed  porcelain  or  iron  tube.  The  resulting  bisulphuret  of  carbon, 
when  purified  by  distillation,  is  a clear  colourless  liquid,  of  a pungent 
taste.  Its  specific  gravity  is  1’272.  It  is  very  volatile,  boiling  at 
108°. 

It  has  been  stated  in  various  literary  journals,  that  bisulphuret 
of  carbon  has  lately  been  used  as  an  anaesthetic  agent  at  Christiania  ; 
but  no  particulars  regarding  its  employment  in  Norway  have,  so  far 
as  I know,  been  yet  published. 

I have  breathed  the  vapour  of  bisulphuret  of  carbon,  and  ex- 
hibited it  to  about  twenty  other  individuals,  and  it  is  certainly  a 
very  rapid  and  powerful  anaesthetic.  One  or  two  stated  that  they 
found  it  even  more  pleasant  than  chloroform  ; but  in  several  it  pro- 
duced depressing  and  disagreeable  visions,  and  was  followed  for 
some  hours  by  headache  and  giddiness,  even  when  given  only  in 
small  doses.  In  one  instance  I exhibited  it,  with  Mr.  Miller’s  per- 
mission, to  a patient,  from  whom  he  removed  a tumour  of  the 
mamma.  It  very  speedily  produced  a full  anaesthetic  effect ; but  it 
was  difficult  to  regulate  it  during  the  operation.  The  patient  was 
restless  in  the  latter  part  of  it,  but  felt  nothing.  Like  several  others 
when  under  it,  her  eyes  remained  wide  open.  After  the  operation 
she  was  extremely  sick,  with  much  and  long-continued  headache  ; 
and,  for  fifty  or  sixty  hours  subsequently,  her  pulse  was  high  and 
rapid,  without  rigor  or  symptoms  of  fever. 

I tried  its  effects  in  a case  of  midwifery,  in  presence  of  Dr.  Weir, 
Dr.  Duncan,  Mr.  Norris,  and  a number  of  the  pupils  of  the  Maternity 
Hospital.  It  was  employed  at  intervals  during  three-quarters  of  an 


BISULPHURET  OF  CARBON. 


169 


hour.  The  patient  was  easily  brought  under  its  influence,  a few 
inspirations  sufflcing  for  that  purpose ; but  it  was  found  altogether 
impossible  to  produce  by  it  the  kind  of  continuous  sleep  attending 
the  use  of  chloroform.  Its  action  was  so  strong,  that  when  given,  as 
a pain  threatened  or  commenced,  it  immediately  affected  the  power 
of  the  uterine  contractions,  so  as  often  to  suspend  them  ; and  yet 
its  effects  were  so  transient  that  the  state  of  anaesthesia  had  gener- 
ally passed  off  within  a minute  or  two  afterwards.  The  patient 
anxiously  asked  for  it  at  the  commencement  of  each  pain.  During 
its  use  she  was  occasionally  sick,  and  vomited  several  times.  Lat- 
terly her  respiration  became  rapid,  and  her  pulse  rose  extremely 
high.  I then  changed  the  inhalation  for  chloroform,  and,  under  it, 
the  patient  slept  quietly  on  for  twenty  minutes,  when  the  child  was 
born.  During  these  twenty  minutes  there  was  no  more  sickness  or 
vomiting,  and  the  pulse  gradually  sunk  down  to  its  natural  standard. 
A few  minutes  after  the  child  was  expelled,  and  while  the  mother 
still  slept,  her  pulse  was  counted  at  80.  Next  day  the  mother  and 
infant  were  both  well,  and  she  has  made  a good  recovery. 

While  these  experiments  prove  the  strong  anaesthetic  properties 
of  bisulphuret  of  carbon,  they  at  the  same  time  show  its  disadvan- 
tages. I have  not  alluded  to  another  strong  drawback  upon  its  use, 
viz.  its  very  unpleasant  odour.  “ It  has,”  says  Dr.  Gregory,  “ a 
peculiarly  offensive  smell  of  putrid  cabbage.”  * By  ’dissolving  various 
essential  oils  in  the  bisulphuret,  I tried  to  overcome  this  disagreeable 
defect,  but  without  much  success. 

None  of  the  five  anaesthetics  which  I have  mentioned  in  the 
present  communication  are,  I believe,  comparable  with  chloroform 
or  sulphuric  ether,  either  in  their  manageableness  or  in  their  effects. 
And  the  after-consequences  which  all  of  them  tend  to  leave,  are  too 
severe  and  too  frequent  to  admit  of  their  introduction  into  practice. 
They  are  more  interesting  physiologically  than  therapeutically. 


1 Outlines  of  Chemistry,  p.  130. 


170 


NATUKE  AND  POWER  OF  ANAESTHETIC  AGENTS. 


CHAPTER  ly. 

ANAESTHETIC  AND  SEDATIVE  PROPERTIES  OF  BICHLORIDE  OF 
CARBON,  OR  CHLOROCARBON. 

Edinhurgh,  December  1865. 

Lately  I have  inhaled  apd  used  a liquid  the  vapour  of  which  seems 
to  me  to  approach  nearer  in  its  quality  and  effects  to  chloroform 
than  any  other  anaesthetic  agent.  The  fluid  I refer  to  is  one  of  the 
chlorides  of  carbon. 

In  describing  the  products  of  the  action  of  chlorine  on  one  of 
the  anaethetic  fluids  mentioned  above — namely,  chloride  of  hydro- 
carbon, or  Dutch  liquid — Mr.  Fownes  states  (see  his  Manual  of 
Chemistry,  seventh  edition,  p.  445)  that  three  or  four  chlorides  of 
carbon  can  be  artificially  made  from  Dutch  liquid  by  the  abstraction 
of  successive  portions  of  hydrogen  and  its  replacement  by  equivalent 
quantities  of  chlorine.  He  enumerates  as  belonging  to  this  series — 
1,  Sesquichloride  or  perchloride  of  carbon  (C4Clg);  2,  Protochloride 
of  carbon  (C4CIJ);  3,  Subchloride  of  carbon  (C4CI2);  and  4,  Bichlo- 
ride of  carbon  (C.^CIJ.^ 

The  last  of  these  compounds — the  bichloride  of  carbon — is  the 
new  anaesthetic  which  forms  the  special  subject  of  the  present  obser- 
vations. It  was  first,  I believe,  discovered  by  M.  Regnault,  in  1839. 
It  has  already  received  various  appellations  from  various  chemists, 
as  perchloroformene,  perchlorinated  chloride  of  methyl,  dichloride  of 
carbon,  carbonic  chloride,  tetrachloride  of  carbon,  superchloride  of 
carbon,  perchloruretted  hydrochloric  ether,  and  perchloruretted  for- 
mene  (see  Gmelin’s  Handbook  of  Chemistry,  vol.  vii.,  p.  355,  and 
Watt’s  Dictionary  of  Chemistry,  vol.  i.  p.  7G5). 

If  it  becomes,  as  I believe  it  will,  for  some  medicinal  purposes,  an 
article  of  the  Materia  Medica,  it  will  require  to  have  a pharmaceu- 
tical name  appended  to  it,  and  perhaps  the  designation  of  perchloro- 
formene, or  the  shorter  term  chlorocarbon,  may  prove  sufficiently 
distinctive.  In  its  chemical,  constitution,  bichloride  of  parbon,  or 
chlorocarbon,  is  analogous  to  chloroform  ; with  this  difference,  that 
1 1,  CaClg  ; 2,  C^C'b  ; 3,  ; 4,  CCI4,  by  present  notation.  [Ed.] 


CHLOROCARBON. 


171 


the  single  atom  of  hydrogen  existing  in  chloroform  is  replaced  in 
chlorocarbon  by  an  atom  of  chlorine,  for  the  relative  chemical  con- 
stitution of  these  two  bodies  may  be  stated  as  follows : — 

Chloroform  = C HCl 

Chlorocarbon  = C^ClCb  i 

The  chlorocarbon  can  be  made  from  chloroform  by  the  action 
of  chlorine  upon  that  liquid  ; and  Geuther  has  shown  that  tlie  pro- 
cess may  be  also  reversed,  and  chloroform  produced  from  chlorocarbon, 
by  treating  it  in  an  appropriate  vessel  with  zinc  and  dilute  sulphuric 
acid,  and  thus  exposing  it  to  the  action  of  nascent  hydrogen.  The 
most  common  way  hitherto  adopted  of  forming  bichloride  of  carbon 
consists  in  passing  the  vapour  of  bisulphide  or  bisulphuret  of  carbon 
together  with  chlorine  through  a red-hot  tube  either  made  of  por- 
celain or  containing  within  it  fragments  of  porcelain.  There  result 
from  this  process  chloride  of  sulphur  and  bichloride  of  carbon,  the 
latter  being  easily  separated  from  the  former  by  the  action  of 
potash. 

The  bichloride  of  carbon,  or  chlorocarbon,  is  a transparent, 
colourless  fluid,  having  an  ethereal  and  sweetish  odour,  not  unlike 
chloroform.  Its  specific  gravity  is  great,  being  as  high  as  T56, 
whilst  chloroform  is  T49.  It  boils  at  170°  Fahrenheit,  the  boiling 
point  of  chloroform  being  141°.  The  density  of  its  vapour  is  5'33, 
that  of  chloroform  being  4’ 2. 

Besides  trying  the  ansesthetic  effects  of  bichloride  of  carbon 
upon  myself  and  others,  I have  used  it  in  one  or  two  cases  of  mid- 
wifery and  surgery.  Its  primary  effects  are  very  analogous  to  those 
of  chloroform,  but  it  takes  a longer  time  to  produce  the  same  degree 
of  anaesthesia,  and  generally  a longer  time  to  recover  from  it.  Some 
experiments  with  it  upon  mice  and  rabbits  have  shown  this — two 
corresponding  animals  in  these  experiments  being  simultaneously  ex- 
posed, under  exactly  similar  circumstances,  to  the  same  doses  of 
chloroform  and  chlorocarbon.  But  the  depressing  influence  of 
chlorocarbon  upon  the  heart  is  greater  than  that  of  chloroform  ; and 
consequently,  I believe  it  to  be  far  more  dangerous  to  employ  as  a 
general  ansesthetic  agent.  In  a case  of  midwifery  in  which  it  was 
exhibited  by  my  friend  and  assistant.  Dr.  Black,  and  myself,  for 
above  an  hour,  with  the  usual  anaesthetic  effects,  the  pulse  latterly 
became  extremely  feeble  and  weak.  In  another  case  in  which  it 
was  exhibited  by  Dr.  Black,  the  patient,  who  had  taken  chloroform 

^ Chloroform  CHCI3  ; Chlorocarbon  CCICI3,  by  present  notation.  [Ed.] 


172 


NATURE  AND  POWER  OF  ANAESTHETIC  AGENTS. 


several  times  before,  was  unaware  that  the  new  anaesthetic  was 
different  from  the  old ; her  pulse  continued  steady  and  firm, 
although  she  is  the  subject  of  valvular  disease  of  the  heart.  The 
surgical  operations  in  which  I have  used  chlorocarbon  have  been,  the 
closure  of  a vesico-vaginal  fistula,  the  division  of  the  cervix  uteri,  the 
enlargement  of  the  orifice  of  the  vagina,  and  the  application  of 
potassa  fusa  to  a large  flat  naevus  upon  the  chest  of  a young  infant. 
In  all  of  these  cases  it  answered  quite  w'ell  as  an  anaesthetic.  The 
child  did  not  waken  up  for  more  than  an  hour  and  a half  after  the 
employment  of  the  caustic,  which  was  used  so  as  to  produce  a large 
slough.  Its  pulse  was  rapid  and  weak  during  the  greatest  degree 
of  anaesthetic  sleep.  One  of  the  mice  exposed  to  its  influence,  and 
which  was  removed  from  the  tumbler  where  the  experiment  upon  it 
was  made  as  soon  as  the  animal  fell  over,  breathed  imperfectly  for 
some  time  after  being  laid  on  the  table,  and  then  died. 

Chlorocarbon,  when  applied  externally  to  the  skin,  acts  much 
less  as  a stimulant  and  irritant  than  chloroform,  and  will  hence,  I 
believe,  in  all  likelihood  by  found  of  use  as  a local  anaesthetic  in  the 
composition  of  sedative  liniments. 

In  two  cases  of  severe  hysteralgia  I have  injected  air  loaded 
with  the  vapours  of  chlorocarbon  into  the  vagina.  The  simplest 
apparatus  for  this  purpose  consists  of  a common  enema  sj^ringe,  with 
the  nozzle  introduced  into  the  vagina,  and  the  other  extremity  of 
the  apparatus  placed  an  inch  or  more  down  into  the  interior  of  a four- 
ounce  phial,  containing  a small  quantity — as  an  ounce  or  so — of  the 
fluid  whose  vapour  it  is  wished  to  inject  through  the  syringe.  Both 
patients  were  at  once  temporarily  relieved  from  the  pain.  The  first 
patient  told  me  her  relief  at  the  first  application  of  the  anaesthetic 
vapour  was  so  long  that  she  slept  during  the  following  night  far 
more  soundly  than  she  had  done  for  weeks  previously. 

The  injection  of  the  vapour  of  chlorocarbon  into  the  rectum  does 
not  prove  so  irritating  as  the  vapour  of  chloroform.  In  one  case  it 
removed  speedily  pains  in  the  abdomen  and  back. 

Chloroform  vapour  applied  by  sprinkling  a few  drops  on  the 
hand,  and  held  near  the  eye,  is  one  of  the  very  best  and  most  seda- 
tive collyria  in  some  forms  of  conjunctivitis,  ulcerations  of  the  cornea, 
with  photophobia,  etc.  I have  not  yet  tried  the  vapour  of  chloro- 
carbon, but  perhaps  it  may  answer  still  better,  as  less  irritant,  and 
almost  as  strongly  sedative. 

I have  found  teu  or  twenty  drops  injected  subcutaneously  by 
Dr.  Wood’s  syringe  repeatedly  relieve  local  pains  of  the  walls  of  the 


CIILOllOCAHBON. 


173 


chest,  abdomen,  etc.,  without  being  followed  by  the  distressing 
nausea  so  frequently  the  result  of  the  hypodermic  injection  of  pre- 
parations of  opium  and  morphia. 

Internally  I have  only  hitherto  tried  it  in  small  doses  in  gas- 
trodynia,  where  it  has  the  same  effect  as  swallowing  a capsule  of 
chloroform. 

The  specimen  of  chlorocarboii  which  I have  used  was  made  by 
Mr.  Ransford,  who  sent  it  down  to  Messrs.  Duncan,  Flockhart,  and 
Company,  of -Edinburgh,  under  the  idea  that,  by  a chemical  substi- 
tution, it  might  be  converted  into  chloroform,  and  make  a cheap 
medium  for  the  manufacture  of  the  latter  drug.  And  perhaps  I 
may  be  permitted  here  to  remark  that  the  quantity  of  chloroform 
used  is  now  becoming  very  great,  and  possibly  might  be  rendered 
greater  if  it  could  be  produced  at  a still  cheaper  rate.  Me  have 
two  or  three  manufactories  for  chloroform  in  this  city.  The  chief 
of  these  manufactories  for  it — that  of  Messrs.  Duncan,  Flockhart, 
and  Company — now  make  upwards  of  7000  doses  of  chloroform 
every  day,  counting  two  drachms  as  a full  dose  ; they  thus  send  out 
nearly  2,500,000  doses  a-year.  Are  every  two  million  and  a-half  full 
doses  which  are  used  of  opium,  antimony,  aloes,  Epsom  salts,  etc., 
attended  with  as  little  danger  and  as  few  ultimate  deaths  as  these 
annual  2,500,000  doses  of  chloroform  ] 


PAET  IV. 


APPLICATIONS  OF  ANESTHESIA  IN  SUEGEKY 
AND  MEDICINE. 


CHAPTER  I. 

CONDITIONS  FOR  INSURING  SUCCESSFUL  ANESTHESIA  IN  SURGERY, 
CAUTIONS,  ETC. 

Edinburgh,  September  1847. 

To  produce  the  full  and  perfect  effects  of  etherisation,  it  is  neces- 
sary to  conduct  the  process  in  conformity  with  certain  conditions. 
These  conditions  it  is  not  the  object  of  the  present  communica- 
tion to  consider.  But  I will  take  the  liberty  of  mentioning  two 
or  tliree  leading  points,  the  importance  of  which,  in  relation  to 
the  attainment  of  complete  success,  has  become  strongly  impressed 
upon  my  own  mind  by  a somewhat  extensive  experience  in  etherisa- 
tion during  the  last  few  months. 

First,  The  patient  ought  to  be  left,  as  far  as  possible,  in  a state 
of  absolute  quietude  and  freedom  from  mental  excitement,  both 
during  the  induction  of  etherisation,  and  during  his  recovery  from 
it.^  All  talking  and  all  questioning  should  be  strictly  prohibited. 

^ The  area  of  an  hospital  operation  theatre  is  hence,  perhaps,  not  the  most 
favourable  place  for  securing  all  the  advantages  of  etherisation,  or  rather  for 
shunning  all  its  disadvantages.  Lately,  in  a case  in  which  Professor  Miller  per- 
formed partial  amputation  of  the  foot,  in  the  Royal  Infirmary,  I etherised  the  boy 
who  was  the  subject  of  it,  in  his  bed  in  the  Avards.  He  was  carried  in  this  state 
up  stairs  to  the  operating  theatre — the  amputation  performed — and  the  patient 
brought  back  again  to  his  bed  before  he  Avas  alloAved  to  aAA^ake.  He  Avas  thus,  at 
one  and  at  the  same  time,  entirely  spared  the  moral  shock  and  pain  of  being  trans- 
ported and  carried  in  before  a formidable  collection  of  surgeons  and  students,  and 
saved  from  the  physical  sufferings  attendant  upon  the  amputation  itself ; for  he 
Avas  perfectly  unconscious  of  aught  that  had  occurred,  and,  Avhen  he  aAvoke,  he  AV'as 
not  aware  that  he  had  been  operated  upon,  or  had  even  left  his  bed.  While  being 
carried  from  the  Avard  to  the  operating  room,  the  sponge  Avith  which  he  Avas 
etherised  AA’as  kept  fixed  OA'er  his  face  Avith  a couple  of  common  elastic  letter  bands. 
In  our  surgical  hospitals,  if  a Award  immediately  adjoining  the  operating  theatre 
Avere  set  aside  for  operation  cases,  it  Avould  in  this  Avay  facilitate  the  process  of 
etherisation,  and  insure  more  certain  and  perfect  results  from  it. 


ADMINISTRATION,  ETC. 


175 


In  tins  way  any  tendency  to  excitement  is  eschewed,  and  the  proper 
effect  of  the  ether-inhalation  more  speedily  and  certainly  induced. 
And,  secondly,  with  the  same  view,  the  primary  stage  of  exhilaration 
should  be  entirely  avoided,  or  at  least  reduced  to  the  shortest  pos- 
sible limit,  by  impregnating  the  respired  air  as  fully  with  the  ether 
vapour  as  the  patient  can  bear,  and  by  allowing  it  to  pass  into  the 
lungs  both  by  the  mouth  and  nostrils,  so  as  rapidly  and  at  once  to 
superinduce  its  complete  and  anaesthetic  effect.  Latterly,  I have 
found  that  for  surgical  purposes,  and  when  it  is  not  necessary  to 
keep  up  the  etherisation  above  five  or  ten  minutes,  by  far  the  best 
and  most  perfect  inhaler  is  formed  by  a large  sponge  of  the  common 
hollow  conical  shape,  perforated  artificially  with  a pretty  large  aper- 
ture at  the  apex,  and  placed  over  the  face  like  a mask,  so  as  to 
include  both  the  mouth  and  nose  in  its  concave  base.  At  first,  it 
should  be  held  at  a little  distance  from  the  face,  and  afterwards 
gradually  advanced  to  it,  in  order  to  avoid  exhibiting  the  vapour  in 
too  powerful  and  irritating  a form  for  the  first  few  inspirations.  Its 
interior  should,  immediately  before  using  it,  be  fully  and  freely 
saturated  with  ether — a very  common  but  certainly  a very  unpar- 
donable error  being  to  exhibit  an  imperfect  and  exciting,  instead  of 
a perfect  and  narcotising  dose  of  the  vapour.^  Many  of  the  alleged 
failures  and  misadventures  are  doubtless  entirely  attributable  to  the 
neglect  of  this  simple  rule  ; not  the  principle  of  etherisation,  but 
the  mode  of  putting  it  in  practice  being  altogether  to  blame.  But, 
thirdly,  whatever  means  or  mode  of  etherisation  is  adopted,  the  most 
important  of  the  conditions  required  for  procuring  a satisfactory  and 
successful  result  from  its  employment  in  surgery,  consists  in  obsti- 
nately determining  to  avoid  the  commencement  of  the  operation  itself, 
and  never  venturing  to  apply  the  knife  until  the  patient  is  under 
the  full  influence  of  the  ether-vapour,  and  thoroughly  and  indubitably 
soporised  by  it. 

In  the  operating  theatres  of  the  Paris  hospitals,  the  most  triumph- 

^ AVhen  a prolonged  effect  is  required,  as  in  midwifery  cases,  an  instrument  is 
necessary — were  it  for  no  other  reason  than  the  saving  of  ether,  and  tlie  preven- 
tion of  its  diffusion  through  the  apartment.  Within  the  last  few  days  I have  seen 
a pamphlet  dated  Boston,  May  30,  1847,  in  Avhich  it  is  stated  that  for  three 
months  previously,  all  aj)paratus  had  been  laid  aside,  and  the  sponge  alone  used 
for  etherisation,  by  Dr.  Morton  of  that  city — the  gentleman  to  whom,  I believe, 
the  profession  and  mankind  are  really  and  truly  imlebted  for  first  introducing 
into  practice  the  production  of  insensibility,  by  ether-inhalation,  with  the  object 
of  annihilating  pain  in  surgical  operations. — See  Some  Account  of  the  Lcthcon,  by 
Edward  Warren,  p.  87. 


176 


APPLICATIONS  IN  SUEGERY. 


ant  successes,  in  the  original  trials  with  ether,  were  obtained  by  M. 
Velpeau,  who  differed  from  his  fellows  in  one  all-important  particular 
only — namely,  in  the  forbearance  Avith  which  he  waited  for  the 
complete  insensibility  of  his  patients  before  venturing  to  take  his 
operating  knife  into  his  hand.  Few  men  have  had  more  practice 
in  etherising  than  Dr.  Snow  of  London,  who  has  been  in  the  habit, 
for  some  time  past,  of  thus  assisting  in  their  operations  some  of  the 
first  surgeons  in  the  metropolis.  Speaking  of  the  stage  of  etherisa- 
tion required,  he  draws  a proper  distinction  between  two  degrees  of 
this  state — the  first,  and  slighter,  in  which  the  patient  moves,  and 
winces,  and  seems  to  feel  pain  at  the  moment,  but  without  after- 
Avards  remembering  it ; and  the  second  and  deeper  state  in  Avhich 
there  is  no  evidence  AAdiatever  of  pain  being  felt,  far  less  remembered. 
And  he  adds,  “ In  full  four-fifths  of  the  cases  in  Avhich  he  had  ad- 
ministered the  ether,  there  was  not  the  least  flinch  or  groan  during 
the  cutting  of  the  surgeon’s  knife.  He  considered  cases  of  this  kind 
the  only  truly  successful  ones,  and  believed  that  Avith  proper  care 
every  case  might  be  of  this  nature.  When  the  patient  exhibited 
signs  of  pain,  although  he  might  have  no  knoAvledge  or  recollection 
of  it  afterwards,  the  ether  Avas  only  partially  successful.”^  As  a 
proof  that  such  deep  states  of  etherisation  are  not  accompanied  with 
danger,  I may  mention  here,  though  in  the  Avay  of  anticipation,  that 
out  of  39  surgical  operations,  “ nearly  all  serious  ones,”  in  Avhich  Dr. 
Snow  has  exhibited  ether  at  St.  George’s  Hospital,  2 only  of  the 
patients  died — namely,  2 on  whom  amputation  of  the  thigh  Avas 
performed,  after  they  had  been  previously  reduced  to  an  “ extremely 
Aveak  and  emaciated”^  state.  Noav,  2 deaths  in  39  hospital  opera- 
tions, or  1 in  1 8,  Avould  certainly  be  regarded  as  a very  satisfactory 
and  favourable  result  under  almost  any  circumstances,  and  either 
Avith  or  Avithout  ether.  Dr.  Peacock,  in  his  official  reports  of  the 
Edinburgh  Infirmary  for  1842  and  1843,  has  published*^  two  tables 
showing  the  results  of  the  “ principal  operations  ” in  that  institution, 
from  amputation  and  lithotomy  doAvn  to  the  operation  for  harelip. 
The  tables  include  150  cases  in  all;  and  32  of  the  150  patients 
operated  upon  died,  or  about  1 in  every  5.  Excluding  57  cases  of 

^ Medical  Gazette,  February  26,  1847 ; and  Braithwaite’s  Betros'pect  of  Medicine, 
vol.  XV.  1847,  p.  409.  2 Lancet  for  May  29,  1847,  p.  553. 

2 Statistical  Tables  of  the  Royal  Infirmary  of  Edinburgh  for  1842,  p.  xix. ; 
and  for  1843,  p.  xviii.  In  the  reports  of  other  years  the  operations  are  unfortu- 
nately not  talnilatod  on  the  same  plan,  and  do  not  show  the  mortality  dependent 
upon  them. 


ADMINISTRATION,  ETC. 


177 


“ extirpation  of  tumours  in  various  parts,”  32  in  the  93  individuals 
on  whom  other  operations  were  performed,  or  nearly  1 in  every  3 
died. 

Edinburgh,  Ibth  December  1847. 

To  produce  the  complete  anoesthetic  and  soporific  effects  of  the 
chloroform,  some  conditions  are  necessary  to  he  attended  to.  With- 
out attending  to  these  conditions,  you  will  have  failures.  1.  The 
chloroform  vapour  must  always  be  exhibited  as  rapidly,  and  in  as 
full  strength  as  possible,  if  you  desire  to  have  its  first  or  exhilarat- 
ing stage  practically  done  away  with,  and  excluded ; and  you  effect 
this  by  giving  the  vapour  so  powerfully  and  speedily  as  to  apathise 
the  patient  at  once.  If  you  act  otherwise,  and  give  it  in  small  or 
slow  doses,  you  excite  and  rouse  the  patient  in  the  same  way  as  if 
nitrous  oxide  gas  were  exhibited.  2.  In  order  that  the  patient  be 
thus  brought  as  speedily  as  possible  under  its  full  influence,  the 
vapour  should  be  allowed  to  pass  into  the  air-tubes  by  both  the 
mouth  and  nostrils — and  hence  all  compression  of  the  nostrils,  etc., 
is  to  be  avoided.  3.  The  vapour  of  chloroform  is  about  four  times 
heavier  than  atmospheric  air.  And  hence,  if  the  patient  is  placed 
on  his  back  during  its  exhibition,  it  will,  by  its  mere  gravitation, 
force  itself  in  larger  quantities  into  the  air-passages  than  if  he  were 
erect  or  seated.  As  to  the  best  instrument  for  exhibiting  the  chloro- 
form with  these  indications,  the  simple  handkerchief  is  far  preferable 
to  every  means  yet  adopted.  It  is  infinitely  preferable  to  any 
instrument  I have  yet  seen,  some  of  which  merely  exhibit  it  by  the 
mouth,  and  not  by  the  nostrils,  in  small  and  imperfect,  instead  of 
full  and  complete  doses  ; and  with  instruments  so  constructed,  there 
is  no  doubt  whatever  that  failures  and  exciting  effects  would  ever 
and  anon  occur.  Besides,  inhaling  instruments  frighten  patients, 
whilst  the  handkerchief  does  not ; and  mental  excitement  of  all 
kinds,  from  whispering  and  talking  around  the  patient,  is  to  be 
strictly  avoided,  if  possible.  As  to  the  quantity  required  to  be 
applied  to  the  handkerchief,  it  has  been  stated,  that  the  average 
dose  of  a fluid  drachm  was  generally  sufficient  to  affect  an  adult ; 
but  I have  latterly  seldom  measured  the  quantity  used.  We  must 
judge  by  its  effects,  more  than  its  quantity.  The  operator,  gathering 
his  handkerchief  into  a cup-like  shape  in  his  hand,  should  wet  f reely 
the  bottom  of  the  cup  (so  to  speak),  and  if  the  patient  is  not  affected 
in  a minute  or  so,  he  should  add  a little  more.  It  evaporates 
rapidly ; and  you  must  not  wet  your  handkerchief,  and  then  delay 
for  a minute  or  more  in  applying  it.  It  must  be  applied  imme- 


178 


APPLICATIONS  IN  SUKGERY. 


diately.  Not  unfreqiiently,  when  the  patient  is  just  becoming 
insensible,  he  will  withdraw  his  face,  or  forcibly  push  aside  the 
handkerchief.  If  you  then  fail  to  re-apply  it  to  his  face,  and  keep  it 
there,  you  will  be  liable  to  leave  him  merely  excited.  But  probably 
two  or  three  inhalations  more  will  note  render  him  quite  insensible. 
The  simplest  test  of  its  full  and  perfect  effect,  is  some  noise  or 
stertor  in  the  respiration.  Cease  it  as  soon  as  this  is  fully  set  in. 
But  re-apply  it,  of  course,  from  time  to  time,  if  it  is  wished  to  keep 
up  its  effects. 

Dr.  Bennett  has  spoken  of  the  stertor,  or  some  other  symptom 
being  “ serious.”  Now,  this  and  other  terms  are,  it  is  believed, 
calculated  to  excite  unnecessary  fear.  “Serious”  was  a relative  and 
conventional  term,  constantly  liable  to  be  altered  by  increased  know- 
ledge and  experience.  Twenty  years  ago,  travelling  at  the  rate  of 
thirty  miles  an  hour  would  have  been  reckoned  a very  serious 
matter.  Now-a-days  every  one  knew  it  was  not  so.  The  tyro  looks 
at  first  upon  the  symptoms  of  an  aggravated  attack  of  hysteria  as 
very  serious.  The  physician  of  more  experience  knows  they  are  not 
so.  The  stertorous  breathing,  the  spasms,  and  almost  convulsive 
symptoms,  etc.,  sometimes  produced  by  chloroform,  may  appear 
serious  to  those  who  have  had  little  experience  in  the  use  of  this 
agent.  But  every  one  who  has  seen  much  of  its  effects,  knows  that 
there  is  no  danger  following,  nor  is  there  inconvenience  left,  after 
such  a show  of  serious  symptoms. 

The  strength  and  purity  of  the  chloroform  employed  are  essen- 
tial elements  of  success.  Professor  Gregory  has  examined  about  a 
dozen  specimens  which  he  had  procured  from  various  shops,  here  and 
> in  Glasgow.  Several  of  them  were  by  no  means  of  the  standard 
strength.  A medical  friend  two  days  ago  asked  me  if  I had  ever 
failed  obtaining  the  effects  of  chloroform  upon  any  person.  I 
replied,  never  in  any  one  case.  My  friend  added  that  he  had,  the 
night  previously,  been  unable  to  influence  a parturient  patient, 
though  he  had  given  her  an  ounce.  On  inquiry,  I found  he  had 
used  chloroform  from  a shop  where,  according  to  Dr.  Gregory’s 
researches,  it  was  sold  under  a specific  gravity  of  P200,  instead  of 
being  1*480. 

Edinburgh,  February  185G. 

During  the  last  few  months,  since  an  untaxed  “ methylated 
spirit”  has  come  to  be  employed  for  pharmaceutical  purposes,  chloro- 
form has  been  extensively  manufactured  from  methylated  instead  of 
common  .spirit ; and  apparently  of  equally  good  quality.  In  conse- 


ADMINISTRATION,  ETC. 


170 


qiience  of  the  comparative  cheapness  of  methylated  spirit,  chloroform 
is  thus  further  reduced  about  one-third  in  price.  See  its  price  in 
1852  (p.  146) ; and  the  remark  or  prediction  (p.  159)  made,  at  its 
first  introduction  into  practice,  in  1848,  when  chloroform  cost  four 
shillings  per  ounce. 

Instead  of  using  a folded  towel  or  handkerchief,  or  still  more 
complex  instrument  for  exhibiting  chloroform,  it  will  be  found,  that 
when  its  application  is  required  in  small  and  repeated  quantities,  the 
concavity  of  the  hand  of  the  patient  or  attendant  is  generally  the 
simplest  and  safest,  and  certainly  the  readiest  and  the  least  formid- 
able instrument,  AVlien  inhaling  it,  for  example,  to  allay  coughs, 
bronchitis,  pneumonia,  laryngismus,  fits  of  pertussis,  etc.,  it  is  suffi- 
cient, in  many  cases,  to  contract  the  semifiexed  hand  into  a cup 
form — to  pour  a few  drops  of  chloroform  into  the  concavity  of  the 
palm  — and  immediately  hold  the  hand  thus  prepared  over  the 
mouth,  the  patient  at  the  same  time  breathing  fully  and  deeply. 
The  heat  of  the  human  hand  speedily  evaporates  the  liquid.  In  the 
same  way,  in  irritable  and  scrofulous  ophthalmia,  etc.,  holding  over 
the  affected  eye  the  concave  hand,  wetted  with  a few  drops  of 
chloroform,  forms  often  the  best  collyrium  to  the  diseased  organ, 
and  is  a practice  which  in  general  speedily  removes  the  distressing 
supersensibility  to  light  attendant  upon  some  forms  of  ulcerative 
corneitis,  etc.  The  adoption  of  the  same  simple  means  in  painful 
fissures  and  ulcers  of  the  nipple,  in  irritable  cutaneous  ulcers  and 
eruptions,  etc.,  is  too  evident  to  require  specification. 

Edinburgh,  litli  November  1860. 

For  some  time  past  I have  administered  chloroform  in  a manner 
somewhat  different  from  that  in  which  it  was  formerly  used ; and  I 
believe  that  by  the  new  method  the  patient  is  more  rapidly  anaes- 
thetised, whilst  a great  saving  is  effected  in  the  amount  of  the  drug 
employed.  The  difference  of  the  two  modes  consists  in  this,  that 
according  to  the  old  plan  the  fluid  is  poured  upon  a cloth  folded 
into  several  layers,  and  the  hand  of  the  administrator  has  to  be  kept 
between  the  cloth  and  the  patient’s  face  in  order  to  secure  the  due 
access  and  admixture  of  air  ; while  in  following  out  the  new  method, 
one  single  layer  of  a towel  or  handkerchief  is  laid  over  the  patient’s 
nose  and  mouth,  care  being  taken  not  to  cover  the  eyes,  and  on  this 
single  fold  the  chloroform  is  poured,  drop  by  drop,  until  complete 
ansesthesia  is  induced.  There  is  little  or  none  of  the  drug  lost  by 
evaporation  when  it  is  administered  in  this  manner,  for  the  patient 


180 


APPLICATIONS  IN  SURGERY. 


inhales  it  at  the  moment  when  it  is  poured  on  the  cloth,  and  in- 
hales it  mixed  with  a sufficient  quantity  of  air,  which  is  easily 
inspired  through  a single  layer  of  an  ordinary  napkin.  Dr.  Moir 
has  long  been  in  the  habit  of  administering  chloroform  in  this  way, 
and  I believe  that  this  manner  of  using  chloroform  will  add  to  the 
safety  of  its  employment.  I have  often  feared  lest  the  lives  of 
patients  should  be  sacrificed  by  the  careless  manner  in  which,  in 
particular,  students  and  young  practitioners  sometimes  employ  the 
damp  folded  cloth  over  the  patient’s  face  without  admitting  a suffi- 
cient supply  of  air  ,;  and  no  doubt  many  of  the  deaths  attributed  to 
chloroform  are  due  only  to  the  improper  administration  of  it,  and 
are  consequently  no  more  chargeable  on  the  drug  itself  than  are  the 
many  deaths  resulting  from  overdoses  of  opium,  etc.  etc.  But  the 
dangers  from  carelessness  and  improper  administration  would  be 
diminished  were  there  never  placed  over  the  patient’s  nose  and 
mouth  more  than  one  single  layer  of  cloth,  moistened  with  a few 
drops  of  fluid.  The  first  patient  to  whom  I administered  it  in  this 
manner  had  been  chloroformed  several  times  previously,  and  had 
never  gone  to  sleep  till  an  ounce  and  a half  or  two  ounces  of  the. 
fluid  had  been  used ; but  when  administered  drop  by  drop  on  a 
single  layer  of  a thin  towel  one  drachm  sufficed  to  induce  the  most 
profound  sleep.  It  has  thus  all  the  advantages  that  have  ever 
been  claimed  for  the  complicated  apparatus  which  some  medical 
men  are  still  in  the  habit  of  using.  There  is  only  one  precaution 
to  be  attended  to  in  employing  chloroform  in  this  manner,  viz. — 
care  must  be  taken  to  anoint  the  lips  and  nose  of  the  patient  before- 
hand with  oil  or  ointment,  to  prevent  the  skin  being  injured  by  the 
contact  of  the  fluid  with  the  patient’s  face,  resulting  from  the  close 
application  of  the  wetted  towel. 

Edinburgh,  1855. 

In  the  icay  of  caution  in  the  employment  of  chloroform,,  the 
points  that  demand  the  principal  attention  are  the  following : — 
1.  The  drug  employed  should  be  as  pure  as  possible,  and  free  from 
those  various  deleterious  ingredients  that  are  sometimes  found 
mixed  up  with  it,  and  which  are  liable  to  produce  cough,  headache, 
etc.  2.  In  its  exhibition  there  ought  always  to  be  allowed  to  enter 
with  the  vapour  of  chloroform  a free  intermixture  of  atmospheric 
air,  the  fingers  of  the  exhibitor  being  for  this  purpose  always  kept 
placed  at  one  side  between  the  face  of  the  patient  and  the  chloro- 
formed towel  or  handkerchief ; and  3.  Its  action  should  always  be 
suspended,  and  the  handkerchief  or  instrument  containing  it  instantly 


ADMINISTKATION,  ETC. 


181 


removed,  whenever  snoring  and  stertor  supervene  in  the  respira- 
tion, or  when  the  pulse  becomes  languid,  and  falls  much  below  the 
natural  standard ; or  when  the  face  and  lips  greatly  alter  in  their 
colour  either  to  pallor  or  lividity. 

When  in  any  case  too  powerful  and  large  a dose  of  chloroform 
is  given,  the  means  of  recovery  which  ought  to  be  pursued  are 
chiefly  the  following: — 1.  The  instant  removal  of  the  chloroform 
handkerchief  or  instrument,  and  of  everything  containing  the  liquid, 
from  the  neighbourhood  of  the  patient.  2.  The  supine  position. 
3.  The  free  access  of  pure  air  to  his  face.  4.  If  necessary,  the  per- 
formance and  continuance  of  artificial  respiration  by  alternate  com- 
pression and  relaxation  of  the  walls  of  the  chest,  or  other  means, 
taking  special  care  at  the  same  time  to  pull  forward  the  tongue  in 
the  first  instance,  provided  it  has  fallen  backwards  on  the  top  of 
the  windpipe.  Some  authorities  have  recommended  the  use  of  gal- 
vanism if  an  apparatus  be  at  hand,  the  inhalation  of  oxygen  or 
ammonia,  inversion  of  the  body,  etc.  No  liquid  should  be  poured 
into  the  mouth  of  the  patient  till  he  is  able  to  swallow. 


It  is  a very  important  question  whether  all  should  be  subjected 
to  the  influence  of  anaesthetics,  or  wdiether  there  are  any  diseased 
states  of  the  system  which  contra-indicate  the  employment  of  those 
agents. 

The  following  are  the  chief  diseases  which  have  been  alleged  to 
afford  instances  of  such. 

Among  pulmonary  diseases  phthisis  with  haemoptysis  was  thought 
at  one  time  to  forbid  the  employment  of  anaesthetics,  but  it  has 
since  been  proved,  that,  so  far  from  being  injurious,  chloroform  is 
highly  beneficial,  and  is  now  used  pretty  extensively  to  allay  the 
distressing  cough  which  accompanies  that  fatal  disease. 

Pneumonia  was  also  held  to  forbid  the  induction  of  anaesthesia ; 
nay,  it  was  even  supposed  that  chloroform  had  often  the  effect  of 
producing  pneumonia.  But  now,  on  the  contrary,  that  agent  is 
used  to  a great  extent  on  the  Continent  in  the  treatment  of  that 
affection,  forming  often  the  only  remedy  employed. 

Among  nervous  diseases  epilepsy  may  be  mentioned  as,  accord- 
ing to  some,  contra-indicating  the  exhibition  of  chloroform. 

Most  practitioners  were  in  the  habit  of  withholding  that  drug  if 
a patient  was  affected  with  epilepsy ; and  many  even  still  do  so.  It 
is  maintained  by  some  that  chloroform  is  most  valuable  in  helping 


182 


APPLICATIONS  IN  SUKGEPY. 


US  to  diagnose  between  true  and  feigned  epilepsy,  as  in  the  first  it 
invariably  causes  a fit,  while  in  the  latter  it  merely  produces  its 
usual  effects.  Dr.  Snow  tells  us,  however,  that  this  is  an  incorrect 
statement,  for  though  it  does  very  frequently  bring  on  a fit,  in  some 
cases  of  undoubted  epileptic  patients  chloroform  may  be  pushed  to 
its  highest  effects  without  the  occurrence  of  one.  Even  though  an 
attack  be  induced,  it  will  be  much  less  severe  than  usual,  and  will 
soon  cease  if  the  inhalation  be  gone  on  with,  so  that  this  affection 
is  no  true  contra-indication. 

Hysteria  is  situated  very  like  epilepsy,  because,  though  chloro- 
form may  bring  on  a paroxysm,  that  will  soon  subside  if  the  inhala- 
tion be  continued. 

In  photophobia  arising  from  scrofulous  ulcerations,  and  also  in 
some  cases  of  conjunctivitis  where  the  little  patient  is  quite  unable 
to  turn  his  eyes  to  the  light,  if  a few  drops  of  chloroform  be  placed 
on  the  hand  and  held  close  to  the  eye,  the  vapour  will  act  as  a 
sedative,  and  the  child  will  be  able  to  open  its  eyes,  so  that  a proper 
examination  can  be  made.  I have  even  in  some  cases  been  success- 
ful in  curing  the  disease  by  repeating  the  application  of  the  vapour 
several  times  during  the  day. 

Among  cardiac  diseases  pericarditic  adhesions  do  not,  as  once 
suj^posed,  prohibit  the  employment  of  anaesthesia. 

Valvular  diseases  are  those  which  are  most  generally  considered 
and  insisted  on  as  contra-indicating  the  use  of  chloroform.  But 
this  is  really  not  the  case,  for  that  agent  may  be  employed  without 
the  least  danger  in  any  valvular  disease,  except  perhaps  disease  of 
the  mitral  valve.  This  is  the  only  affection  -where  I have  the  least 
hesitation  in  administering  chloroform.  There  is  perhaps  no  neces- 
sity for  this  dread  after  all.  Dr.  Snow  thinks  that  there  is  no 
single  disease  that  contra-indicates  the  employment  of  ansesthetics, 
and  concludes  “ that  this  agent  [chloroform]  when  carefully  admi- 
nistered, causes  less  disturbance  of  the  heart  and  circulation,  than 
does  severe  pain.” 


ILLUSTRATIVE  CASES. 


183 


CHAPTER  11. 

CASES  ILLUSTRATIVE  OF  THE  USE  AND  EFFECTS  OF 
CHLOROFORM  IN  SURGERY. 

Edinhurgh,  November  1847. 

I HAVE,  through  the  great  kindness  of  Professor  Miller  and  Dr. 
Duncan,  had  an  opportunity  of  trying  the  effects  of  the  inhalation 
of  chloroform,  in  three  cases  of  operation  in  the  Royal  Infirmary 
of  Edinburgh.  A great  collection  of  professional  gentlemen  and 
students  witnessed  the  results,  and  among  the  number  was  Professor 
Dumas  of  Paris,  the  chemist  who  first  ascertained  and  established 
the  chemical  composition  of  chloroform.  He  happened  to  be  passing 
through  Edinburgh,  engaged,  along  with  Dr.  Milne  Edwards  who 
accompanied  him,  in  an  official  investigation  for  the  French  govern- 
ment, and  was  in  no  small  degree  rejoiced  to  witness  the  wonderful 
physiological  effects  of  a substance  with  whose  chemical  history  his 
own  name  was  so  intimately  connected. 

I append  notes  obligingly  furnished  to  me  by  Professor  Miller 
and  Dr.  Duncan,  of  the  three  cases  of  operation.  The  first  two 
cases  were  operated  on  by  Professor  Miller ; the  third  by  Dr. 
Duncan.  In  applying  the  chloroform  in  the  first  case,  I used  a 
pocket-handkerchief  as  the  inhaling  instrument ; in  the  last  two  I 
employed  a hollow  sponge. 

Case  I. — “A  boy,  four  or  five  years  old,  with  necrosis  of  one  of  the  bones  of 
the  forearm.  Could  speak  nothing  but  Gaelic.  No  means,  consequently,  of 
explaining  to  him  what  he  was  required  to  do.  On  holding  a handkerchief,  on 
which  some  chloroform  had  been  sprinkled,  to  his  face,  he  became  frightened, 
and  wrestled  to  be  away.  He  was  held  gently,  however,  by  Dr.  Simpson,  and 
obliged  to  inhale.  After  a few  inspirations  he  ceased  to  cry  or  move,  and  fell 
into  a sound  snoring  sleep.  A deep  incision  was  now  made  down  to  the  diseased 
bone,  and,  by  the  use  of  the  forceps,  nearly  the  whole  of  the  radius,  in  the  state 
of  sequestrum,  was  extracted.  During  this  operation,  and  the  subsequent 
examination  of  the  wound  by  the  finger,  not  the  slightest  evidence  of  the  suffering 
of  pain  was  given.  He  still  slept  on  soundly,  and  was  carried  back  to  his  ward 
in  that  state.  Half-an-hour  afterwards,  he  was  found  in  bed,  like  a child  newly 
awakened  from  a refreshing  sleep,  with  a clear  merry  eye,  and  placid  expression 
of  countenance,  wholly  unlike  what  is  found  to  obtain  after  ordinary  etherisation. 

68 


184 


APPLICATIONS  IN  SUKGEEY. 


On  being  questioned  b}’’  a Gaelic  interpreter,  who  was  found  among  the  students, 
he  stated  that  he  had  never  felt  any  pain,  and  that  he  felt  none  now.  On  being 
shown  his  wounded  arm,  he  looked  much  surprised,  but  neither  cried  nor  ex- 
pressed the  slightest  alarm.” 

Case  II. — “A  soldier  who  had  an  opening  in  the  cheek — the  result  of  exfolia- 
tion of  the  jaw — was-  next  made  to  inhale.  At  first  he  showed  some  signs  of 
moving  his  hands  too  freely  ; but  soon  also  fell  into  a state  of  sleep  and  snoring. 
A free  incision  was  made  across  the  lower  jaw,  and  from  this  the  dense  adhering 
integuments  were  freely  dissected  all  round,  so  as  to  raise  the  soft  parts  of  the 
cheek.  The  edges  of  the  ojiening  were  then  made  raw,  and  the  whole  line  of 
incision  was  brought  together  by  several  points  of  suture.  This  patient  had 
previously  undergone  two  minor  operations  of  a somewhat  similar  kind  ; both  of 
them  had  proved  unsuccessful,  and  he  bore  them  very  ill — proving  unusually  un- 
steady, and  complaining  bitterly  of  severe  pain.  On  the  present  occasion,  he  did 
not  wince  or  moan  in  the  slightest  degree  ; and,  on  the  return  of  consciousness, 
said  that  he  had  felt  nothing.  His  first  act,  when  apparently  about  half-awake, 
was  suddenly  to  clutch  up  the  sponge  with  which  the  chloroform  was  used,  and 
re-adjust  it  to  his  mouth,  obviously  implying  that  he  had  found  the  inhalation 
from  it  anything  but  a disagreeable  duty. 

“This  case  was  further  interesting  as  being  one  of  those  operations  in  the 
region  of  the  mouth,  in  which  it  has  been  deemed  impossible  to  use  ether — and 
certainly  it  would  have  been  impossible  to  have  performed  the  operation  with  any 
complicated  inhaling  apparatus  applied  to  the  mouth  of  the  patient.” 

Case  III. — “ A young  man,  of  about  twenty-two  years  of  age,  having  necrosis 
of  the  first  phalanx  of  the  great  toe,  and  ulceration  of  the  integuments,  the  con- 
sequence of  injury.  The  ulcerated  surface  was  exceedingly  tender  to  the  touch — 
so  much  so,  that  he  winced  whenever  the  finger  was  brought  near  to  it  ; and  the 
slightest  pressure  made  him  cry  out.  After  the  removal  of  the  dressings,  which 
caused  some  pain  and  fretting,  the  inhalation  was  commenced,  and  the  patient 
almost  immediately^  became  insensible,  and  lay  perfectly  still,  while  the  diseased 
mass  was  being  removed  by  amputation  of  the  toe  through  the  middle  of  the 
second  phalanx.  The  inhalation  was  now  stopped.  The  edges  of  the  wound 
were  then  brought  together  with  three  stitches,  and  the  Avound  dressed.  The 
patient  shortly  afterwards  awoke,  looked  round  him,  and  gratefully  declared  his 
entire  and  perfect  freedom  from  all  pain  and  uneasiness  during  the  operation.  ” 

The  whole  quantity  of  chloroform  used  in  these  three  operations 
did  not  exceed  half-an-ounce — and,  as  Professor  Miller  afterwards 
observed  to  the  students  that  were  present,  if  ether  had  been  used, 
several  ounces  of  it  would  have  been  requisite  to  produce  the  same 
amount  of  anjesthetic  effect 

The  following  case  occurred  also  to-day,  to  Mr.  Miller,  in  private 
practice.  The  notes  of  it  and  the  subsequent  remark  are  in  his  own 
words. 

Case  IV. — “ A young  lady  wished  to  have  a tumour  (ency.sted)  dissected  out 
rom  beneath  the  angle  of  the  jaw.  The  chloroform  was  used  in  small  quantity 

1 Dr.  Christison,  who  was  Avatching  the  result,  informs  me  that  this  patient 
was  affected  in  half-a-minute. 


ILLUSTRATIVE  CASES. 


185 


(about  a drachm)  sprinkled  upon  a piece  of  operation  sponge.  In  considerably  less 
than  a minute  she  M^as  sound  asleep,  sitting  easily  in  a chair,  with  her  eyes  shut, 
and  with  her  ordinary  expression  of  countenance.  The  tumour  was  extirpated, 
and  a stitch  inserted,  without  any  pain  having  been  either  shown  or  felt.  Her 
sensations  throughout,  as  she  subsequently  stated,  had  been  of  the  most  pleasing 
nature  ; and  her  manageableness  during  the  operation  was  as  perfect  as  if  she  had 
been  a wax  doll  or  a lay  figure,” 

“Ho  sickness,  vomiting,  headache,  salivation,  uneasiness  of  chest,  in  any  of 
the  cases.  Once  or  twice  a tickling  cough  took  place  in  the  first  breathings.” 

I have,  up  to  this  date,  exhibited  the  chloroform  to  about  fifty 
individuals.  In  not  a single  instance  has  the  slightest  bad  result 
of  any  kind  whatever  occurred  from  its  employment. 


186 


APPLICATIONS  IN  MEDICINE. 


CHAPTER  III. 

CHLOROFORM  IN  INFANTILE  CONVULSIONS,  AND  OTHER  SPASMODIC 
DISEASES,  IN  PNEUMONIA,  AND  IN  PERITONITIS. 

Edinburgh,  January  1852. 

“ There  are,”  observes  Dr.  Churcliill,‘  “ few  diseases  of  infants 
and  children  which  are  more  formidable  or  more  fatal  than  convul- 
sions.” The  great  number  of  deaths  from  convulsions,  especially  in 
infancy,  which  appears  in  all  our  published  Mortality  Returns,  so  far 
bears  out  the  justness  of  Dr.  Churchill’s  remark.  During  the  five 
years  from  1838  to  1842  included,  there  occurred,  according  to  the 
Registrar-General’s  official  returns,  127,276  deaths  from  convulsions 
in  England  and  Wales.^  Of  these  deaths,  amounting  to  about 
25,000  annually,  almost  all  are  among  children  below  five  years  of 
age  ; and  the  greatest  proportion  of  cases  and  deaths  takes  place 
among  infants  during  the  first  year,  or  rather  during  the  first  months 
or  weeks  of  life.^ 

AVithout  entering  into  the  question  of  the  nature  of  the  different 
types  or  forms  of  convulsions  observable  in  early  life,  I shall  content 
myself,  at  present,  with  referring  to  the  general  opinion  of  patho- 
logists, that  by  far  the  greatest  proportion  of  infantile  convulsive 
attacks  are  sympathetic  or  functional  merely  ; — a predisposition  to 
the  disease  being  laid  by  an  undue  excitability,  or  super-polarity 
of  the  cerebro-spinal,  or  rather  “ true  spinal  ” or  reflex  system  of 
Dr.  Marshall  Hall ; and  the  immediate  exciting  cause  of  the  affec- 
tion being  usually  traceable  to  some  morbific  irritation  of  a distant 
excitant  surface  or  part,  as  the  stomach,  bowels,  teeth,  etc.  Hence 
when  the  disease  proves  fatal  under  this  form,  no  organic  lesions  are 

^ Diseases  of  Children,  p.  97. 

2 Seventh  Annual  Deport  of  the  Registrar -General,  p.  63. 

3 “ The  frequency  of  convulsions  has,  in  my  practice,  appeared  most  consider- 
able in  the  first  month  of  life  ; from  this  period  the  disease  becomes  gradually 
rarer  up  to  the  fifth  month,  and  then  again  more  common  up  to  the  period  when 
the  incisor  teeth  make  their  appearance.  After  this  age,  the  disease  again 
becomes  rare.” — See  observations  of  Dr.  Schoepf  Merei,  formerly  Professor  of  the 
Diseases  of  Children  in  the  University  of  Pesth,  in  Monthly  Journal  for  1850, 
p.  566. 


IN  SPASMODIC  DISEASES. 


187 


usually  detected.  “ Dissections,”  says  Dr.  Merei,  “ have  incontestably 
established,  that  in  the  great  majority  of  cases  of  infantile  convul- 
sions terminating  fatally,  there  is  no  cerebral  or  spinal  inflammation, 
nor  even  evidence  of  active  vascular  congestion.”  ^ 

Consequently,  in  cases  of  inflintile  convulsions,  particularly  when 
of  a sympathetic,  reflex,  or  eccentric  type,  after  removing  all  the 
traceable  exciting  sources  of  irritation,  and  diminishing  any  excess  of 
vascular  action  in  the  nervous  centres,  physicians  have  generally 
proceeded  to  combat  the  disease,  if  it  still  persisted,  with  medicinal 
agents  that  tended  to  reduce  the  super-irritability  of  the  excito- 
motory  system,  or  otherwise  to  restore  it  to  its  proper  and  healthy 
standard  of  action.  To  fulfil  this  indication,  preparations  of  zinc, 
iron,  etc.,  have  been  used  in  the  more  chronic  cases  ; and  in  the 
more  acute  or  sub-acute  cases,  antispasmodics  of  very  different  kinds, 
as  opium,  hyoscyamus,  musk,  etc.,  have  been  generally  employed. 
In  the  following  instance,  after  all  the  ordinary  means  of  treatment 
failed,  chloroform  was  used  as  an  antispasmodic  with  the  most  marked 
and  satisfactory  effect. 

Case. — The  Viscountess was  confined  on  the  7th  October.  The  child, 

a boy,  kept  quite  well  till  the  17th  of  the  same  month,  when  it  was  observed  by 
its  nurse,  two  or  three  times  during  the  day,  to  have  twitchings  in  the  muscles  of 
the  face  ; but  they  were  not  so  severe  as  to  attract  any  very  special  attention. 
During  the  two  following  days  these  convulsive  twitchings  were  repeated  with 
rather  greater  frequency  ; the  hands  were  observed  to  be  clenched  during  them, 
and  the  thumbs  were  turned  inwards. 

On  Monday  the  20th,  the  convulsions  became  far  more  violent  in  their 
character,  were  more  prolonged  in  their  duration,  and  were  repeated  with  much 
greater  frequency.  They  continued  with  little  change,  and  no  abatement  in  their 
intensity  or  frequency,  for  the  next  fourteen  days.  Sometimes  they  affected  the 
right  side  of  the  body  much  more  severely  than  the  left.  In  the  meantime.  Dr. 
Scott  and  I tried  a great  variety  of  means  for  their  relief ; but  all  in  vain.  The 
bowels  were  well  acted  upon  with  mercurials,  magnesia,  etc.  ; and  every  separate 
function  attempted  to  be  brought  as  near  as  possible  to  the  standard  of  health. 
A new  wet  nurse  was  procured,  lest  the  milk  might  perchance  have  been  proving, 
as  it  sometimes  does,  the  source  of  irritation.  The  child  was  placed  in  a larger 
and  better  ventilated  room.  Ice  and  iced- water  v-ere  occasionally  applied  to  the 
scalp.  At  one  time,  when  the  fits  became  unusually  prolonged,  and  were  not  only 
accompanied,  but  followed  for  a time,  by  much  congestion  in  the  vessels  of  the 
scalp  and  face,  and  an  elevated  state  of  the  anterior  fontanelle,  two  leeches  were 
applied.  Liniments  of  different  kinds  were  used  along  the  spine.  Musk,  with 
alkalies,  was  given  perse veringly  for  several  days,  as  an  antispasmodic  ; and  small 
doses  of  opium,  turpentine  enemata,  etc.,  were  exhibited  with  the  same  view. 

^ Monthly  Journal  for  1850,  p.  566.  See  also  Rilliet  et  Barthez’s  excellent 
work  {Maladies  dcs  Enfans),  vol.  ii.  p.  281  ; North’s  Practical  Observations  on 
Convulsions  of  Infants^  p.  45  ; Bouchut’s  Manuel  Pratique  des  Maladies  des 
Nouveaux-N^s,  p.  387  ; etc.  etc. 


188 


APPLICATIONS  IN  MEDICINE. 


All  these  and  other  means,  however,  proved  entirely  futile.  As  I have  already 
stated,  it  was  on  Monday  the  20th  October  that  the  fits  first  assumed  a severe 
character,  and  they  continued  ■without  any  amelioration  for  about  fourteen  days 
from  that  period,  recurring  sometimes  as  frequently  as  ten  or  twelve  times  in  an 
hour.  At  last  the  child,  who  had  hitherto  wonderfully  maintained  his  strength 
and  power  of  suction,  began  to  show  symptoms  of  debility  and  sinking ; and 
during  the  fifteenth  and  sixteenth  days  of  the  attack  the  fits  became  still  more 
violent,  and  more  distressing  in  their  character.  They  were  now  accompanied 
with  moans  and  screams  that  were  very  painful  to  listen  to  ; symptoms  of  laryn- 
gismus and  dyspnoea  supervened  towards  the  termination  of  each  fit ; and  in  the 
intervals  the  respiration,  as  well  as  the  pulse,  continued  much  quickened. 

During  these  two  last  days  of  the  disease,  the  exhaustion  became  so  great,  the 
dyspnoea  in  the  intervals  so  distressing,  and  the  fits  so  very  violent  and  constant 
(seventeen  being  counted  in  one  hour),  that  Dr.  Scott  and  I gave  up  all  hopes  of 
the  possible  survival  of  the  infant.  We  had  exhausted  all  the  usual  means  of 
relief.  Ultimately,  but  much  more  with  the  view  of  abating  the  screaming,  laryn- 
gismus, and  other  distressing  symptoms  under  which  the  little  patient  was 
suffering,  than  with  any  great  hope  of  permanent  relief  and  cure,  I placed  the 
child,  on  the  forenoon  of  the  5th  November,  for  about  an  hour  under  the  influence 
of  the  inhalation  of  chloroform.  During  this  hour  there  was  no  recurrence  of  the 
fits  ; but  in  a short  time  after  the  withdrawal  of  the  action  of  the  anaesthetic,  the 
convulsions  recommenced  with  their  old  violence  and  frequency.  The  benefit, 
however,  was  sufficient  to  encourage  a longer  repetition  of  the  remedy  ; and  from 
four  to  eight  o’clock  in  the  afternoon  of  the  same  day,  my  assistant.  Dr.  Drum- 
mond, placed  and.  kept  the  child  again  under  the  influence  of  chloroform — a few 
inhalations,  from  time  to  time,  of  a very  small  quantity  of  the  drug  sprinkled  upon 
a handkerchief,  and  held  before  the  face  of  the  infant,  being  sufficient  fcr  this  pur- 
pose. It  was  specially  applied  at  any  threatening  of  the  recurrence  of  a fit,  and 
during  the  four  hours  in  question  all  convulsions  were  in  this  "way  repressed. 
When  the  child  was  allo’vv^ed  to  waken  up  at  eight  o’clock,  it  took  the  breast 
gi’eedily,  and  continued  well  for  upwards  of  an  hour,  when  the  convulsions  again 
began  to  recur.  At  last,  about  twelve  o’clock  p.m,,  it  was  again  placed  under  the 
inhalation  of  chloroform,  and  kept  more  or  less  perfectly  under  its  action  for  up- 
wards of  twenty-four  continuous  hours,  with  the  exception  of  being  allowed  to 
awaken  eight  or  ten  times  during  that  period  for  the  purpose  of  suction  and 
nourishment.  During  most  of  this  period  it  was  carefully  watched  by  Dr.  Drum- 
mond, and  at  last  the  nurse  was  entrusted  with  the  duty  of  adding  the  few'  drops 
of  chloroform  to  the  handkerchief,  and  exhibiting  them  at  any  time  the  child  w'as 
offering  to  aw'aken  or  become  restless. 

After  this  long  continuation  of  the  chloroform,  the  child,  on  being  allow'ed  to 
waken  up,  as  usual  drank  greedily  at  the  nipple,  and  immediately  fell  back  into 
a quiet  and  apparently  natural  sleep.  The  chloroform  and  all  other  formal  medi- 
cation was  in  consequence  discontinued  ; and  from  this  time  there  w'as  subse- 
quently no  recurrence  whatever  of  the  convulsions.  In  about  ten  days  the  child 
was  removed  with  the  family  to  the  country.  I have,  within  the  last  tw’o  days 
(December  18, 1851),  seen  the  child  as  it  was  passing  through  Edinburgh.  It  was 
strong,  plump,  and  well-grown  for  a child  of  ten  Aveeks,  and  was,  in  fact,  revel- 
ling in  the  best  of  health. 

In  exhibiting  the  chloroform  to  this  infant,  ten  ounces  of  the  drug  were  ex- 
pended ; but  of  course  a very  large  proportion  of  this  quantity  Avas  lost  by 
evaporation,  in  consequence  of  the  mode  in  Avhich  it  was  employed. 


IN  SPASMODIC  DISEASES. 


189 


I have  known  the  inhalation  of  chl6roform  similarly  useful  in 
other  cases  in  arresting  infantile  convulsions ; but  I am  not  acquainted 
with  any  instance  in  which  the  patient  was  so  young  as  in  the  above 
instance.  In  the  adult  also,  especially  in  cases  of  puerperal  convul- 
sions, I have  now  repeatedly  seen  the  inhalation  of  chloroform  as 
signal  and  satisfactory  in  its  antispasmodic  power  over  the  convulsive 
fits,  as  it  was  in  the  little  patient  whose  case  I have  described.  Te- 
tanus and  epilepsy  have  been  temporarily  arrested  and  controlled  by 
it.  And  perhaps  it  will  yet  be  found  one  of  our  most  certain  and 
beneficial  therapeutic  means  in  the  functional  forms  of  those  dif- 
ferent convulsive  or  spasmodic  diseases  that  are  produced  either  by 
an  undue  excitability  of  the  true  spinal  system,  or  by  distant  morbid 
irritations  acting  through  this — the  excito-motory  system.  Such 
reflex  convulsive  or  spasmodic  affections  are,  as  is  well-known,  par- 
ticularly common  in  infancy  and  childhood.  I have  seen  its  use  arrest 
laryngismus,  colic,  hiccup,  etc. ; and  cases  have  been  detailed  to  me  of 
its  occasional  successful  use  in  asthma,  spasmodic  urethral  stricture, 
etc.  But  there  is  one  common  and  too  fatal  spasmodic  disease, 
almost  confined  to  the  period  of  childhood,  in  which  I have  seen 
anassthetic  inhalations  successful  in  arresting  and  controlling  the 
paroxysms,  and  where  probably  a more  extended  and  persevering 
use  in  the  employment  of  them  would  be  found  to  be  attended  with 
beneficial  effects.  I allude  to  hooping-cough.  I have  known  chloro- 
form-inhalations greatly  abate  the  irritability  of  the  cough  attendant 
upon  phthisis,  etc.  But  with  others,  I have  scrupled  to  use  chloro- 
form-inhalations in  hooping-cough,  under  the  fear  that  they  might 
possibly  increase  the  great  predisposition  which  exists  in  this  affection 
to  pneumonic  inflammation,  or  aggravate  that  inflammation  if  it  were 
already  present.  This  a 'priori  reason,  however,  against  the  use  of 
chloroform-inhalations  as.  an  antispasmodic  in  hooping-cough,  has 
been  of  late  set  aside  by  the  observations  and  experience  of  different 
German  physicians.  In  a paper,  containing  some  remarks  relative 
to  the  medical  uses  of  chloroform,  published  December  1847,*  in 
addition  to  its  employment  as  an  antispasmodic,  anodyne,  etc.,  I 
suggested  the  possibility  of  the  drug  acting  as  a contra-stimulant  in 
some  inflammatory  diseases,  and  particularly  in  those  of  a painful 
kind.  Latterly,  we  have  had  records  published  of  its  employment 
in  upwards  of  200  cases  of  pneumonia  in  German  practice.  Out  of 
193  cases  of  pneumonia  treated  with  chloroform-inhalations  by 
Wachern,  Baumgartner,  Helbing,  and  Schmidt,  9 patients  died,  or 

1 See  p.  163. 


190 


APPLICATIONS  IN  MEDICINE. 


the  mortality  amounted  to  4;^  per  cent.  Dr.  Yarrentrapp  has  given 
chloroform  in  23  cases  of  pneumonia  in  the  Frankfort  Hospital. 
One  of  these  23  patients  died.^  The  detailed  results  in  the  other 
22  cases  seem  to  have  been  sufficiently  satisfactory.^  At  all  events, 
the  effects  of  the  chloroform-inhalations  upon  the  cough,  expectora- 
tion, etc.,  and  upon  the  general  course  of  the  disease,  would  appear  to 
show  that  we  need  have  no  fear  of  deleterious  effects  from  it,  so  far  as 
regards  the  chance  or  existence  of  pulmonary  inflammation ; what- 
ever advantages  we  may  derive  from  it  in  relation  to  its  prevention  of 
that  inflammatory  state,  by  allaying  the  cough,  keeping  the  lungs  in 
a relative  state  of  quietude,  and  abating  or  restraining  the  succession 
of  characteristic  spasmodic  attacks.  I speak,  of  course,  of  the  more 
severe  cases  of  pertussis ; for  the  milder  forms  of  it  require  care 
merely,  rather  than  actual  treatment. 


Edinburgh,  29th  July  1863. 

Chloroform  in  Acute  Inflammation. — Most  of  us  have  from  time  to 
time  met  with  cases  of  peritonitis  in  which  opium  refused  to  sub- 

^ It  is  proper  to  add,  that  during  the  time  that  these  23  cases  of  pneumonia  were 
admitted  into  the  Frankfort  Hospital,  and  treated  in  that  institution  by  chloroform- 
inhalations,  three  other  cases  of  the  same  disease  presented  themselves,  where  the 
patients,  at  the  time  of  application,  were  already  in  a hopeless  state.  Chloroform 
was  not  tried  with  them. 

2 Out  of  these  23  cases  of  pneumonia  reported  by  Varrentrapp,  in  addition  to 
chloroform,  the  first  was  treated  by  venesection  and  antimony ; a second  case  was 
bled  ; and  two  others,  that  were  complicated  with  pleurisy,  had  calomel  exhibited 
and  blisters  applied ; the  remainder  were  treated  with  chloroform  alone,  about  sixty 
drops  being  placed  upon  a piece  of  cotton,  the  vapour  inhaled  for  ten'or  fifteen  minutes, 
and  the  dose  repeated  every  two,  three,  or  four  hours.  It  was  not  given  so  rapidly 
or  strongly  as  to  produce  unconsciousness.  The  patients  were  all  adults  ; the  mean 
period  of  the  disease  at  their  entrance  into  the  hospital  was  the  fourth  day ; and  the 
chloroform-treatment  was  usually  commenced  on  the  following  morning.  The 
effects  of  the  chloroform-inhalations  seemed  generally  to  be — 1.  The  induction  of 
perspiration,  sometimes  after  the  first  inhalation,  in  no  case  later  than  the  third 
or  fourth.  2.  Gradual  diminution  and  ultimate  disappearance  of  pain  in  the 
thorax  or  side.  3.  Relief  of  the  feeling  of  thoracic  tightness.  4.  Daily  decrease 
of  the  frequency  of  respiration  from  thirty-seven  per  minute  (the  average  on  ad- 
mission) down  to  the  natural  standard.  5.  In  all  cases,  without  an  exception,  the 
cough  was  lessened  by  the  inhalation,  the  intervals  betw’een  the  coughs  shortening, 
the  cough  itself  being  less  violent,  and  the  expectoration  looser  ; the  sputa  gradu- 
ally losing  their  red  tinge,  and  diminishing  in  quantity.  6.  The  pulse  fell 
rapidly  in  frequency  (down  to  eighty  on  an  average  on  the  fifth  day  of  treatment), 
and  the  fever  diminished  gradually,  in  one  case  suddenly.  7.  Good  and  comfort- 
able sleep  ensued  on  an  average  on  the  third  or  fourth  day  after  the  commence- 
ment of  the  chloroform-inhalations. — See  Henle’s  Zeitschrift  fur  llationelle  Medicin, 
and  the  London  Medical  Times  for  October  18,  1851. 


IN  SPASMODIC  DISEASES. 


191 


due  the  symptoms,  and  was  rejected,  as  well  as  the  wine,  brandy, 
and  other  medicines  tha^  were  attempted  to  be  administered.  I 
have  at  present  under  my  care  the  case  of  a lady  who  took  an 
attack  of  peritonitis  ten  days  ap;o.  At  first  it  seemed  very  slight ; 
but  on  the  fourth  day  she  grew  much  w^orse,  the  pain  becoming 
intense,  and  the  pulse  almost  imperceptible.  She  took  large  and 
repeated  doses  of  opium  ; but  as  the  symptoms  continued  unabated, 
I began  in  the  evening  to  make  her  inhale  chloroform.  It  was 
with  some  difficulty  that  she  was  brought  under  its  influence ; 
but  when  she  had  once  been  fairly  anaesthetised,  the  pulse  gradually 
became  stronger  and  steadier.  All  night  she  was  kept  asleep  by 
this  means,  and  on  the  following  day  the  pulse  was  better,  the  pain 
easier,  and  the  patient  seemed  comparatively  out  of  danger.  Until 
three  days  ago,  she  seemed  to  progress  favourably,  when  symptoms 
of  hepatitis  showed  themselves.  These  were  subdued,  and  once 
more  she  began  to  recover.  But  the  day  before  yesterday  she  again 
became  collapsed.  Chloroform  was  administered  with  the  same 
salutary  effect,  and  at  the  present  time  she  is  tolerably  comfortable. 

Chloroform  is  much  used  on  the  Continent  as  a remedial  agent 
in  pneumonia  and  some  other  acute  inflammations  ; but  as  I am  not 
aware  of  its  having  been  used  specially  in  peritonitis,  the  suggestion 
may  prove  helpful  in  some  rare  but  very  distressing  cases  of  that 
disease. 


PART  V. 


APPLICATIONS  OF  ANESTHESIA 
IN  MIDWIFEEY. 


* * “Not  poppy,  nor  mandragora, 

Nor  all  the  drowsy  syrups  of  the  world, 

Shall  ever  medicine  thee  to  such  sweet  sleep.” 

Shakespeare. 


CHAPTER  1. 

ON  THE  INHALATION  OF  SULPHURIC  ETHER  IN  THE  PRACTICE 
OF  MIDWIFERY. 

Edinhurcjli,  March  1847. 

Abundant  evidence  has  of  late  been  adduced,  and  is  daily  accumu- 
lating, in  proof  of  the  inhalation  of  sulphuric  ether  being  capable,  in 
the  generality  of  individuals,  of  producing  a more  or  less  perfect 
degree  of  insensibility  to  the  pains  of  the  most  severe  surgical 
operations.  But  whilst  this  agent  has  been  used  extensively,^  and 
by  numerous  hands,  in  the  practice  of  surgery,  I am  not  aware  that 
any  one  has  hitherto  ventured  to  test  its  applicability  to  the  prac- 
tice of  midwifery.  I am  induced,  therefore,  to  hope  that  the  few 
following  hurried  and  imperfect  notes  relative  to  its  employment  in 
obstetric  cases,  may  not,  at  the  present  time,  prove  uninteresting  to 
the  profession. 

Within  the  last  month  I have  had  opportunities  of  using  the 
inhalation  of  ether  in  the  operation  of  turning,  in  cases  of  the  em- 
ployment of  the  long  and  of  the  short  forceps,  as  well  as  in  several 
instances  in  which  the  labour  was  of  a natural  type,  and  conse- 
quently required  no  special  form  of  artificial  aid. 

The  first  case  in  which  I employed  the  ether  vapour,  occurred 

^ In  a lecture  delivered  to  the  Royal  College  of  Surgeons,  Edinburgh,  on  27th 
IMarch  1868,  Dr.  James  Simpson  stated  that  Dr.  Scott  of  Dumfries  Avas  the  first 
in  this  country  to  make  trial  of  sidphuric  ether  in  surgery.  [Ed.] 


SULPIIUKIC  ETIIEPw 


193 


on  the  19th  of  January  1847/  The  pelvis  of  the  mother  was 
greatly  contracted  in  its  conjugate  diameter  from  the  projection 
forwards  and  downwards  of  the  promontory  of  the  sacrum ; the 
lumbar  portion  of  the  spine  was  distorted  ; and  she  walked  very 
lamely.  The  present  was  her  second  confinement.  Her  first  labour 
had  been  long  and  difficult ; she  began  to  suffer  on  a Monday,  and 
after  a protracted  trial  of  the  long  forceps,  was  at  last  delivered  by 
craniotomy  late  on  the  subsequent  Thursday  night.  Even  after  the 
cranium  had  been  fully  broken  down,  a considerable  time  and  much 
traction  had  been  required  to  drag  the  diminished  and  mutilated 
head  of  the  infant  through  the  contracted  brim  of  the  pelvis ; and 
she  was  long  in  recovering.  Contrary  to  the  urgent  advice  of  her 
medical  attendant,  Mr.  Eigg,  he  was  not  made  aware  of  her  present 
or  second  pregnancy  till  she  had  arrived  at  nearly  the  end  of  the 
ninth  month.  It  was  thus  too  late  to  have  recourse  to  the  induc- 
tion of  premature  labour,  which  had  been  strongly  pressed  upon  her 
as  the  only  means  of  saving  her  child,  should  she  again  fall  in  the 
family  way.  The  pains  of  her  second  labour  commenced  in  the 
forenoon  of  the  1 9th.  I saw  her,,  with  Mr.  Figg,  at  five  o’clock  in 
the  afternoon,  and  again  at  seven.  The  os  uteri  was  pretty  well 
dilated,  the  liquor  amnii  not  evacuated,  the  presenting  head  very 
high,  mobile,  and  difficult  to  touch ; and  a pulsating  loop  of  the 
umbilical  cord  was  felt  floating  below  it  in  the  unruptured  bag  of 
membranes.  From  five  to  nine  o’clock  the  pains  seemed  only  to 
push  the  circle  of  the  os  uteri  farther  downwards,  witliout  increas- 
ing its  dilatation,  or  making  the  head  in  any  degree  enter  into  the 
pelvic  brim.  Assisted  by  Dr.  Zeigler,  Dr.  Keith,  and  Mr.  Figg,  I 
shortly  after  nine  o’clock  made  the  patient  inhale  the  ether  vapour. 
As  she  afterwards  informed  us,  she  almost  immediately  came  under 
the  anodyne  influence  of  the  ether ; but  in  consequence  of  doubts 
upon  this  point,  its  use  was  continued  for  nearly  twenty  minutes 
before  I proceeded  to  turn  the  infant,  as  I had  previously  predeter- 
mined to  do.  A knee  was  easily  seized,  and  the  child’s  extremities 
and  trunk  readily  drawn  down ; but  extreme  exertion  was  required 
in  order  to  extract  the  head.  At  length  it  passed  the  contracted 
brim,  with  the  anterior  part  of  its  right  parietal  bone  deeply  indented 
by  pressure  against  the  projecting  promontory  of  the  sacrum,  and 
the  whole  cranium  flattened  and  compressed  laterally.  The  infant 
gasped  several  times,  but  full  respiration  could  not  be  established. 

^ See  Edin.  Monthly  Journal  of  Medical  Science^  February  1847,  p.  639,  and 
communicated  to  Obstetric  Society,  Edinburgh,  January  20,  1847. 


194 


APPLICATIONS  IN  MIDWIFERY. 


The  transverse  or  biparietal  measurement  of  its  head,  at  tlie  site  of 
the  indentation,  was,  in  its  compressed  state,  not  more  than  2^ 
inches.  Hence  we  judged  the  conjugate  diameter  of  the  pelvic 
brim  not  to  exceed  this.  The  infant  was  large,  and  rather  above  the 
usual  size.  It  weighed  eight  pounds.  On  afterwards  examining  the 
head  and  removing  the  scalp,  no  fracture  could  be  found  at  the  seat 
of  indentation.  The  thin  parietal  bone  had  merely  bent  inwards. 

On  questioning  the  patient  after  her  delivery,  she  declared  that 
she  was  quite  unconscious  of  pain  during  the  whole  period  of  the 
turning  and  extracting  of  the  infant,  or  indeed  from  the  first  minute 
or  two  after  she  first  commenced  to  breathe  the  ether.  The  inhala- 
tion was  discontinued  towards  the  latter  part  of  the  operation,  and 
her  first  recollections  on  awaking  were  “ hearing,”  but  not  “ feeling,” 
the  head  of  the  infant  “jerk”  from  her  (to  use  her  own  expressions), 
and  subsequently  she  became  more  roused  by  the  noise  caused  in 
the  preparation  of  a bath  for  the  child.  She  quickly  regained  full 
consciousness,  and  talked  with  gratitude  and  wonderment  of  her 
delivery,  and  her  insensibility  to  the  pains  of  it.  Next  day  I found 
her  very  well  in  all  respects.  I looked  in  upon  her  on  the  24th,  the 
fifth  day  after  delivery,  and  was  astonished  to  find  her  up  and  dressed, 
and  she  informed  me  that  on  the  previous  day  she  had  walked  out 
of  her  room  to  visit  her  mother.  Mr.  Figg  informs  me  that  her 
further  convalescence  has  been  uninterruptedly  good  and  rapid. 

I have  previously  alluded  to  two  cases  of  delivery  by  the  for- 
ceps, in  which  the  patients  were  under  the  action  of  ether  at  the 
time  of  the  operation.  The  woman  in  the  first  of  these  cases  was 
brought  into  the  Eoyal  Maternity  Hospital,  in  strong  labour,  early 
on  the  morning  of  the  3d  February.  It  was  her  second  confine- 
ment. At  her  first  accouchement,  seven  years  before,  she  had  been 
delivered  by  instruments,  in  Ireland,  and  had  been  informed  by  the 
attendant  practitioner  that  artificial  delivery  would  be  similarly 
required  at  her  future  labours.  I saw  her  between  ten  and  eleven 
o’clock  A.M.  The  os  uteri  was  well  dilated,  the  membranes  rup- 
tured, and  the  pains  extremely  strong  and  frequent ; but  the  large 
head  of  the  child  seemed  not  to  enter  fully  into  the  brim,  and  was 
little  affected  by  the  powerful  uterine  contractions  under  which  the 
patient  was  suffering.  By  three  o’clock  her  pulse  had  risen  to  above 
125  beats  a minute,  and  it  appeared  to  the  medical  officers  present 
chat  it  would  be  improper  to  allow  the  ineffectual  and  exhausting 
efforts  of  the  patient  to  be  longer  continued.  She  was  then,  at  my 
request,  brought  under  the  influence  of  ether.  Dr.  Moir,  with  great 


SULPHURIC  ETHER. 


195 


skill,  applied  the  long  forceps  upon  the  head  of  the  child.  He  sub- 
sequently was  obliged  to  use  strong  traction  during  the  pains  that 
followed,  and  becoming  temporarily  fatigued  with  his  efforts,  I 
supplied  his  place.  After  the  head  fully  passed  the  brim,  the 
forceps  were  laid  aside,  and  one  or  two  uterine  contractions  finished 
the  delivery.  The  child  was  large  and  strong,  and  cried  vigorously 
soon  after  it  was  expelled.  During  the  whole  of  this  severe  opera- 
tion the  2)atient  appeared  quiet  and  passive.  The  cries  of  her  child 
speedily  roused  her  from  her  anaesthetised  state,  and  she  subse- 
quently assured  Dr.  Moir  that  she  had  felt  comparatively  little  or 
no  pain  during  the  whole  operation  and  delivery. 

On  the  evening  of  the  12th  February,  I saw  another  forceps 
case,  with  my  friend  Dr.  Graham  Weir.  The  patient  was  advanced 
in  life,  and  it  was  her  first  confinement.  The  waters  had  escaped 
early,  and  the  anterior  lip  of  the  uterus  had  subsequently  become 
forced  down  in  a very  swelled  and  oedematous  state  before  the  head 
of  the  infant.  After  this  obstruction  was  overcome,  the  child’s  head 
speedily  descended  upon  the  floor  of  the  pelvis ; but  it  was  there 
impeded  in  its  farther  progress  by  the  narrow  transverse  diameter 
of  the  outlet.  Under  the  compression  of  the  converging  tuberosities 
of  the  ischia,  the  bones  of  the  foetal  cranium  soon  began  to  overlap ; 
but  at  last,  no  farther  progress  being  made,  the  patient  becoming 
exhausted  by  a continuous  labour  of  about  twenty-four  hours,  and 
the  soft  parts  being  evidently  well  relaxed  and  prepared.  Dr.  Weir 
applied  the  short  forceps,  and  extracted  a living  infant.  For  a con- 
siderable time  before  this  operation  was  adopted,  1 exhibited  the 
vapour  of  ether  to  the  patient ; under  it  she  speedily  became  quite 
narcotised.  Its  action  was  kept  up,  and  the  pains  appeared  to  be 
so  strong  as  almost  to  warrant  the  idea  that  nature  would  yet  be 
sufficient ; but  ultimately,  instrumental  delivery  was,  as  I have 
already  stated,  had  recourse  to.  The  mother  did  not  fully  recover 
from  her  state  of  anassthesia  for  ten  or  fifteen  minutes  after  delivery, 
and  then  stated  that  she  was  quite  unaware  of  anything  that  had 
been  done,  and  of  what  had  occurred.  Dr.  Weir  informs  me  that 
this  patient  was  up  on  the  fourth  day  after  delivery,  and  felt  by 
that  time  so  perfectly  well,  that  she  was  with  difficulty  persuaded 
by  the  nurse  to  abstain  from  walking  about  the  house  as  usual. 

As  far  as  they  go,  the  preceding  cases  point  out  one  important 
result : — in  all  of  them,  the  uterine  contractions  continued  as  regular 
in  their  occurrence  and  duration  after  the  state  of  anaesthesia  had 
been  induced,  as  before  the  inhalation  was  begun.  The  emotion  of 


196 


APPLICATIONS  IN  MIDWIFERY. 


fear  has  appeared  to  me  to  suspend,  in  one  or  two  nervous  patients, 
the  recurrence  of  the  first  pains,  after  the  apparatus  was  adjusted 
and  its  employment  commenced,  but  this  effect  speedily  passed  off ; 
and  as  yet  I have  seen  no  instance  in  which  the  pains  were  sensibly 
diminished  in  intensity  or  frequency  after  the  ether  had  fairly  begun 
to  act.  Indeed,  in  some  cases  they  have  appeared  to  me  to  have 
become  increased  as  the  consciousness  of  the  patient  became  dimi- 
nished. This  has  more  particularly  occurred  with  one  or  two  patients, 
who  breathed  ether,  combined  with  tincture  of  ergot,  or  containing 
a solution  of  its  oil.  A woman  was  brought  into  the  Maternity 
Hospital  on  the  28  th  January,  after  being  in  labour  for  thirty  or 
forty  hours.  It  was  her  second  child.  Subsequently  to  her  enter- 
ing the  hospital,  at  7 P.M.,  scarcely  any  decided  uterine  contrac- 
tion could  be  said  to  take  place.  The  os  uteri  was  well  opened,  but 
the  head  was  still  high  in  the  pelvis ; and  when  I saw  her  at  4 A.M. 
of  the  following  morning,  nine  hours  after  her  entrance  into  the 
hospital,  little  or  no  advance  whatever  had  been  made,  and  the  case 
was  becoming  an  anxious  one.  She  was  then  made  to  inhale  equal 
parts  of  sulphuric  ether  and  tincture  of  ergot.  In  the  course  of  a 
few  minutes  a series  of  extremely  powerful  uterine  contractions 
supervened,  and  the  child  was  born  within  a quarter  of  an  hour 
of  the  commencement  of  inhalation.  The  mother  subsequently 
declared  that  she  recollected  nothing  at  all  of  her  delivery,  except 
the  removal  of  the  after-birth.  In  this  case,  was  the  re-excitement 
of  strong  pains  the  result  of  the  action  of  the  sulphuric  ether,  or  of 
the  ergot,  or  of  both  ? Or  was  it  a simple  but  very  strange  coinci- 
dence ? More  facts  than  I yet  possess  are  necessary  to  decide  such  a 
question  ; but  I have  seen  some  cases  which  lead  me  to  believe  that 
other  therapeutic  agents  besides  those  I have  named  may  be  readily 
introduced  into  the  system  by  means  of  pulmonary  inhalation.^ 

^ Dr.  Richard  Pearson,  who,  in  1795,  was,  I believe,  the  first  person  that 
recommended  the  inhalation  of  sulphuric  ether  as  a therapeutic  agent  (see  his 
Accoimt  of  the  Nature  and  Properties  of  different  kinds  of  Airs,  p.  24),  suggested 
also  the  use  of  it  impregnated  with  opium,  squill,  cicuta,  etc. ; and  he  speaks  of 
the  effect  of  “an  emetic  given  in  this  manner.”  He  employed  the  simple  sul- 
phuric ether  vapour  in  some  cases  of  phthisis,  asthma,  hooping-cough,  croup,  and 
catarrh,  recommending  it  to  be  inhaled  (after  being  reetified  and  washed),  from  a 
cup — through  an  inverted  funnel — or,  with  children,  by  “ wetting  a handkerchief 
with  it,  and  holding  it  near  the  nose  and  mouth.”  See  Medical  Facts  and' Obser- 
vations, for  1797,  vol.  vii.  p.  96.  In  the  thirteenth  volume  of  the  Dictionnaire 
dcs  Sciences  Medicales  (1816),  p.  385,  Nysten  has  deseribed  a particular  ai)paratus, 
like  some  of  our  modern  forms,  for  the  inhalation  of  sulphuric  ether.  See  also 
vol.  xvii.  p.  134.  Vaporisable  substances,  when  introduced  into  the  system  in 


SULPHURIC  ETHER. 


197 


A more  extensive  and  careful  series  of  investigations  tlian  I have 
yet  been  able  to  institute,  may  perhaps  show  that  in  some  constitu- 
tions, and  under  some  circumstances  or  degrees  of  intensity,  the 
process  of  etherisation  may  possibty  interfere  with  the  uterine  con- 
tractility, particularly  in  the  earlier  stages  of  the  labour.^  At  the 
same  time,  various  analogies  would  lead  us  to  expect  that,  as  I have 
hitherto  found,  the  action  of  the  uterus  would  go  on  uninterruptedly, 
when  the  psychical  influence  of  the  mind  and  purely  cerebral  func- 
tions were  suspended,  as  in  the  more  complete  states  of  anaesthesia. 
At  all  events,  if  we  may  judge  from  the  analogous  experiments  of 
Vollkmann,  Bidder,  and  Kolliker,  upon  the  simple  contractions  and 
rhythmic  reflex  actions  of  the  heart,  intestines,  etc.,  the  motory 
nervous  powers  of  the  uterus  belong  to  the  ganglionic  and  to  the 
spinal  systems,  and  are  not  in  any  necessary  dependence  upon  the 
brain  or  mind.  Indeed,  Ollivier  and  Nasse  have  published  cases  of 
perfect  paraplegia,  notwithstanding  which  the  act  of  parturition  in 
the  human  female  proceeded  regularly  in  its  course,  and  without 
conscious  pain.  In  the  one  case  (Ollivier’s),  the  cord  was  compressed 
and  destroyed  from  the  first  to  the  fourth  dorsal  vertebra  by  a col- 
lection of  acephalocysts  and,  in  the  other  instance  (Nasse’s),  com- 
plete paralysis  had  followed  a fracture  of  the  third  and  fourth  cervical 
vertebrae.^  Of  course  such  lesions  necessarily  prevented  the  brain 
exerting  any  influence  upon  the  uterus,  or  its  contractions. 

Long  ago,  in  discussing  this  subject,  Haller  adduced  the  authority 
of  Harvey,  Smellie,  Lamotte,  etc.,  to  prove  that  uterine  contractions 
and  labour  may  go  on  with  the  mother,  “ ignara,  stupida  et  sopita, 
et  immobili,  et  apoplectica,  et  epileptica,  et  convulsionibus  agitata,^  et 
ad  summum  debili.”^  Deneux  mentions  a fact  still  more  in  point, 

this  manner,  probably  pass  undigested  and  unchanged  into  the  circulation,  and 
“ seem  (observes  Wagner)  to  make  their  way  into  the  blood  through  the  unbroken 
vascular  membrane  [of  the  bronchial  cells]  with  the  sa^ne  certainty  and  ease  as 
when  they  are  injected  directly  into  i\iQ  veins.” — {Elements  of  Physiology,  1842, 
p.  443.)  Will  this  not  explain  both  the  rapidity  and  intensity  of  their  actions 
when  thus  used  ? 

1 See  regarding  this,  p.  202,  etc.  [Ed.]  ^ Trciite  de  la  Moelle  Ejnniere,  p.  784. 

2 Untersuchungen  zur  Physiologic,  etc.  Dr.  Cheyne  reports  a case  of  fatal  he- 
morrhagic apoplexy  and  hemiplegia,  in  which,  without  any  apparent  pains,  “the 
uterus  (observes  Dr.  Kellie)  appears  as  an  involuntary  muscle  to  have  acted  in  the 
most  perfect  manner  in  expelling  the  foetus  and  secundines,”  the  day  before  death. 
The  child  was  born  alive. — Cases  of  Apoplexy  and  Lethargy,  pp.  91  and  161. 

^ “During  the  continuance  of  puerperal  convulsions,  uterine  action  is  not 
suspended,  although  no  signs  of  pain  are  manifested  by  the  woman,  if  she  remain 
comatose.” — Dr.  F.  Ramsbotham’s  Obstetric  Medicine  (1844),  p.  455. 

® Elementa  Physiologice,  tom.  viii,  p.  420. 


198 


APPLICATIONS  IN  MIDWIFERY. 


because  in  it  the  analogy  with  the  operation  of  anaesthetics  is  still 
stronger,  or  indeed  identical.  “ A woman,”  says  he,^  “ was  brought 
to  the  Hotel  Dieu  at  Amiens  in  a comatose  state,  in  consequence  of 
her  taking  spirituous  liquors  since  the  commencement  of  labour. 
She  was  delivered  in  the  natural  manner  in  this  state ; the  sleep 
continued  for  some  time  after  delivery.  The  woman,  on  awaking, 
much  surprised  at  finding  her  delivery  completed,  congratulated 
herself  on  having  made  so  happy  a discovery,  and  declared  she 
would  make  use  of  it  if  she  had  again  occasion.”^ 

In  obstetric,  as  in  surgical  practice,  the  degree  of  insensibility 
produced  by  anaesthesia,  and  its  accompanying  phenomena,  differ 
much  in  different  instances.  In  some,  a s^'ate  of  total  apathy  and 
insensibility  seems  to  be  produced  ; others  move  about  and  complain 
more  or  less  loudly  during  the  uterine  contractions,  though  afterwards, 
when  restored  to  their  state  of  common  consciousness,  they  have  no 
recollection  of  any  suffering  whatever,  or,  indeed,  of  anything  that 
had  occurred  during  the  inhalation  and  action  of  the  ether ; others, 
again,  remain  quite  aware  and  conscious  of  what  is  going  on  around 
them,  and  watch  the  recurrence  of  the  uterine  contractions,  but  feel 
indifferent  to  their  effects,  and  not  in  any  degree  distressed  by  their 
presence ; and  in  another  class,  again,  the  attendant  suffering  is 
merely  more  or  less  diminished  and  obtunded,  without  being  perfectly 
cancelled  and  annulled. 

On  the  evening  of  the  13th  inst.,  in  two  cases  that  rapidly  fol- 
lowed each  other,  I witnessed,  in  the  above  respect,  two  very  different 
conditions  induced  by  the  use  of  the  ether.  The  patients,  each  of 
whom  had  borne  several  children  previously,  were  both  placed  under 


^ liccucil  Pcriodique  de  la  Sociele  de  MMicine,  April  1818. 

2 The  celebrated  case  of  tlie  Countess  de  St.  Geran  is  sufficiently  remarkable 
in  relation  to  the  present  subject.  See  full  and  long  details  of  it  in  Gayot’s 
Causes  Celehres,  tom,  i.  pp.  142  to  266.  After  the  Countess  had  been  nine  hours  in 
labour  with  her  first  child,  the  midwife  in  attendance  exhibited  to  her  a potion 
{hrcuvagc),  which  rendered  her  insensible  till  the  following  morning.  When  the 
Countess  then  awoke  to  consciousness,  she  found  herself  bathed  in  blood,  the 
abdominal  tumour  fallen,  and  all  the  signs  of  recent  delivery  present ; but  the 
child  born  during  her  state  of  insensibility  had  been  removed,  and  its  existence  was 
even  denied  to  her.  It  was  years  afterwards  proved,  to  the  satisfaction  of  the  French 
law  courts,  that  the  Countess  had  been  delivered  of  a male  child,  during  an  induced 
lethargic  condition,  and  that  the  infant  had  been  surreptitiously  conveyed  away  to 
a distance,  and  brought  up  as  the  son  of  a poor  man.  The  child’s  claims  W’ere, 
after  much  litigation,  fully  acknowledged  ; he  was  restored  to  his  parents,  and 
ultimately  succeeded  to  his  father’s  title.  AYhat  nepenthean  “ breuvage  ” could 
possibly  produce  the  alleged  effect  ? 


SULPHURIC  ETHER. 


199 


the  influence  of  it  just  as  the  os  uteri  became  fully  opened,  and  in 
neither  did  the  full  expulsion  of  the  infant  through  the  pelvic 
passages  require  above  twelve  or  fifteen  minutes.  My  first  patient, 
the  wife  of  a clergyman,  subsequently  stated,  that  she  knew  all  that 
was  said  and  done  about  her,  was  aware  of  the  pains  being  present, 
but  felt  no  distress  from  any  of  them  till  the  supervention  of  the  last 
strong  contraction,  which  drove  the  head  out  of  the  vulva,  and  the 
feeling  then  seemed  to  partake  of  the  character  of  strong  pressure, 
rather  than  of  actual  pain.  Subsequently  she  told  me  she  could 
only  look  back  with  regret  to  the  apparently  unnecessary  suffering 
she  had  endured  in  the  birth  of  her  former  infants.  The  second 
patient,  a lady  of  a timid  temperament,  and  very  apprehensive 
about  the  result  of  her  present  confinement,  was  induced  with 
difficulty  to  inhale  the  ether  vapour ; but  it  speedily  affected  her 
when  once  she  did  begin.  In  two  or  three  minutes  she  pushed  the 
apparatus  from  her  mouth,  talked  excitedly  to  a female  relative  pre- 
sent, but  was  immediately  induced  to  recommence  the  inhalation ; 
and  subsequently,  according  to  her  own  statement,  “ wakened  out 
of  a dream,  and  unexpectedly  found  her  child  born.”  Like  many 
others,  she  thought  hours  instead  of  minutes  had  elapsed  from  the 
commencement  of  the  inhalation  to  the  period  of  the  complete 
restoration  of  consciousness.  Making  apparently  an  effort  of  me- 
mory, she  afterwards  inquired  if  she  had  not  once  awakened  out  of 
her  dreamy  state,  and  spoken  some  nonsense  to  her  friend. 

A careful  collection  of  cautious  and  accurate  observations  will  no 
doubt  be  required,  before  the  inhalation  of  sulphuric  ether  is  adopted 
to  any  great  extent  in  the  practice  of  midwifery.  It  will  be  neces- 
sary to  ascertain  its  precise  effects,  both  upon  the  action  of  the  uterus, 
and  of  the  assistant  abdominal  muscles ; its  influence,  if  any,  upon 
the  child  ; whether  it  gives  a tendency  to  hemorrhage  or  other  com- 
plications ; the  contra-indications  peculiar  to  its  use  ; the  most  certain 
modes  of  exhibiting  it ; the  length  of  time  it  may  be  employed,  etc.^ 
In  no  case  have  I observed  any  harm  whatever,  to  either  mother  or 
infant,  follow  upon  its  employment.  And,  on  the  other  hand,  I have 
the  strongest  assurance  and  conviction,  that  I have  already  seen  no 

^ I have,  during  labour,  kept  patients  under  its  influence  for  upwards  of  half-an- 
hour.  In  exhibiting  it,  the  first,  or  exhilarating  stage  of  its  effects  should  be  passed 
through  as  rapidly  as  possible,  and  the  patient  never  allowed  to  be  excited  or  irri- 
tated by  the  nurse  or  others.  I have  heard  its  use  strenuously  denounced,  on  the 
ground  that  its  effects,  though  good  and  evanescent,  are  still  of  an  intoxicating 
character.  But  on  the  same  ground,  the  use  of  opium,  etc.  etc.,  in  medicine,, 
to  relieve  pain  and  procure  sleep,  should  be  equally  reprobated  and  discarded. 

61) 


200 


APPLICATIONS  IN  MIDWIFERY. 


small  amount  of  maternal  suffering  and  agony  saved  by  its  applica- 
tion. The  cases  I have  detailed  sufficiently  show  its  value  and  safety 
in  cases  of  operative  midwifery.  And  here,  as  in  surgery,  its  utility 
is  certainly  not  confined  to  the  mere  suspension  and  abrogation  of 
conscious  pain,  great  as,  by  itself,  such  a boon  would  doubtlessly  be. 
But  in  modifying  and  obliterating  the  state  of  conscious  pain,  the 
nervous  sJiock^  otherwise  liable  to  be  produced  by  such  pain — parti- 
cularly whenever  it  is  extreme,  and  intensely  waited  for  and  endured 
— is  saved  to  the  constitution,  and  thus  an  escape  gained  from  many 
evil  consequences  that  are  too  apt  to  follow  in  its  train.^ 

Edinburgh,  November  1847. 

Perhaps  I may  be  excused  for  adding,  that  since  for  the 
first  time  directing  the  attention  of  the  medical  profession  to 
its  great  use  and  importance  in  natural  and  morbid  parturition, 
I have  employed  it,  with  few  and  rare  exceptions,  in  every  case 
of  labour  that  I have  attended ; and  with  the  most  delightful 
results.  And  I have  no  doubt  whatever,  that  some  years  hence  the 
practice  will  be  general.  Obstetricians  may  oppose  it,  but  I believe 
our  patients  themselves  will  force  the  use  of  it  upon  the  profession. 
I have  never  had  the  pleasure  of  watching  over  a series  of  better  and 
more  rapid  recoveries ; nor  once  witnessed  any  disagreeable  result 
follow  to  either  mother  or  child ; whilst  I have  now  seen  an  immense 
amount  of  maternal  pain  and  agony  saved  by  its  employment.  Aijd 
I most  conscientiously  believe  that  the  proud  mission  of  the  physician 
is  distinctly  twofold — namely,  to  alleviate  human  suffering,  as  well 
as  preserve  human  life. 

^ On  the  extent  of  the  nervous  shock  accompanying  human  parturition,  see 
Dr.  Hamilton’s  Practical  Observations,  p.  179,  etc.  ; and  Dr.  Churchill’s  chapter 
on  Convalescence  after  Labour,  in  his  work  on  the  Diseases  of  Pregnancy  and 
Childbed,  p.  240,  etc. 

2 On  what  division  or  divisions  of  the  nervous  system  does  the  nervous  shock 
operate — the  cerebral,  spinal,  or  ganglionic  ? If  on  the  former,  it  should  be  kept 
in  abeyance  by  due  anaesthesia.  Some  years  ago,  I saw  Dr.  J.  Argyll  Robertson, 
when  he  was  Acting  Surgeon  at  the  Royal  Infirmary,  amputate,  at  the  shoulder- 
joint,  an  arm  sadly  shattered  an  hour  or  so  before  by  a railway  injury.  The  man, 
at  the  time  of  receiving  the  injury,  during  the  operation,  and  for  several  hours 
afterwards,  was  in  a state  of  insensibility  from  deep  intoxication  ; and  at  last 
wakened  up,  not  knowing  what  had  happened.  His  recovery  was  rapid  and 
uninterrupted.  AVould  it  have  been  so  if  his  nervous  system  had  been  sufficiently 
alive  to  the  double  shock  of  the  operation  and  injury  ? Out  of  eighteen  cases  of 
primary  amputation,  performed  during  four  years  in  the  Edinburgh  Hospital,  and 
mentioned  in  Dr.  Peacock’s  Report  of  the  Institution  (1843),  this  man  and  another 
patient  were  the  only  two  out  of  the  eighteen  that  survived. 


ADMINISTRATION  OF  CHLOROFORM. 


201 


CHAPTER  11. 

MODE  OF  EXHIBITING  CHLOROFORM  IN  MIDWIFERY  ; DOSE,  ETC. 

Edinhurgh,  October  1848. 

In  the  course  of  the  preceding  observations  I have  omitted  making 
any  remarks  on  the  degree  of  artificial  anaesthesia  required  in  ob- 
stetric practice,  with  the  exception  of  stating  that  when  instrumental 
or  operative  interference  is  adopted,  the  anaesthetic  state  must  be 
made  adequately  deep — so  deep,  that  the  patient  must  be  rendered 
quite  passive  and  apathetic.  In  fact,  when  induced  for  operative 
purposes  in  midwifery,  the  anaesthetic  state  sliould  be  as  complete 
and  profound  as  when  it  is  induced  for  operative  purposes  in  surgery. 
But,  in  common  cases  of  parturition,  the  anaesthetic  agent  employed, 
whether  chloroform  or  ether,  does  not,  in  general,  require  to  be  given 
in  such  large  doses  as  in  surgical  practice.  And  in  obstetric  practice, 
the  rules  which  I have  usually  followed  in  exhibiting  the  chloroform 
(the  only  agent,  I believe,  now  used  in  Edinburgh  and  most  other 
places),  are  those  which  I briefly  stated  when  first  writing  on  the 
subject  in  November  last.  “ After  the  first  full  dose,  a few  inhala- 
tions, before  or  Avith  each  returning  uterine  contraction,  are  generally 
sufficient.  The  state  of  anaesthesia  should  be  made  more  deep  as  the 
head  is  passing  the  perineum  and  vulva.” 

Occasionally  I have  at  first,  and  especially  in  the  early  stages  of 
labour,  given  the  chloroform  in  small  doses  only,  so  as  to  obtund  or 
obliterate  the  sensations  of  pain,  without  altogether  abrogating  the 
state  of  consciousness.  In  many  patients,  this  degree  of  anaesthesia, 
with  the  results  stated — viz.  the  loss,  in  a great  measure,  of  pain 
without  the  entire  loss  of  consciousness — can  be  readily  enough 
induced,  and  answers  excellently  Avell ; but,  as  a general  rule,  it  has 
appeared  to  me  in  some  cases  objectionable.  For  not  unfrequently, 
small  doses,  such  as  produce  this  condition,  are  accompanied  with 
excitem-ent  and  talking ; and  sometimes  patients,  have  complained 
to  me  of  this  renewal  of  the  chloroform  in  small  doses  with  each 
pain,  being  accompanied  each  time  with  a renewal  of  the  ringing  in 

^ Monthly  Journal,  vol.  for  1847-48,  p.  417. 


202 


APPLICATIONS  IN  MIDWIFERY. 


the  ears,  flashes  of  light,  and  other  disagreeable  sensations  accom- 
panying, in  some  persons,  the  primary  effects  of  the  inhalation. 
Besides,  we  are  never  thus  sure  that  we  are  really  saving  the  patient 
to  the  full  extent  by  the  means  we  are  using.  If,  on  the  other  hand, 
she  happen  to  be  thrown  at  once  into  a deeper  state  of  anaesthesia, 
the  chances  of  such  inconveniences  and  drawbacks  are  avoided. 
Often,  when  the  anaesthetic  state  is  thus  made  deep  from  the  first, 
the  uterine  contractions  are  arrested  for  a few  minutes,  but  speedily 
return.  In  order  to  effect  this,  we  take  care  that  as  soon  as  the 
patient  is  asleep — (and,  in  natural  labour,  we  seldom  or  never 
require  to  push  the  inhalation  so  far  as  to  affect  the  respiration, 
and  produce  noisy  inspiration  and  snoring,  as  in  surgery) — the 
chloroform  should  be  withdrawn,  and  not  reapplied  again  till  the 
movements  of  the  patient,  or  the  state  of  the  uterus,  as  felt  through 
the  abdominal  walls,  indicate  a returning  uterine  contraction.  A 
few  inhalations  given  then,  and  repeated  with  each  returning  uterine 
contraction,  keep  the  patient  in  a state  of  unconsciousness ; and 
this  condition  may  be  easily  maintained  for  hours,  by  administering 
in  this  way  the  chloroform  vapour  with  each  pain,  and  withdrawing 
it  entirely  during  each  interval.  The  practice  is  not  to  be  expected 
to  come  upon  medical  men  by  intuition  ; for,  like  all  other  practices, 
some  care  and  experience  is  necessary  in  order  fully  to  acquire  and 
apply  it.  And  the  two  main  difficulties  which  every  beginner  meets 
with  are  these — namely,  to  keep  the  patient  in  a state  unconscious 
of  pain,  and  yet  not  so  deeply  anaesthetised  as  to  have  the  uterine 
action  interrupted.  For  too  deep  a state  of  anaesthesia  in  general 
interferes  with  the  force  and  frequency  of  the  uterine  contractions ; 
while  a lesser  degree  of  the  anaesthetic  state  leaves  these  contractions 
unaffected  ; and  a still  smaller  dose  often  excites  and  increases  them 
— the  effects,  in  this  respect,  of  chloroform  upon  the  uterus,  being 
similar  to  the  effects  of  opium  in  different  doses.  But  the  influence 
of  the  inhaled  agent  passes  off  in  a few  minutes,  differing  in  this 
respect  from  the  more  permanent  influence  of  a drug  when  swallowed ; 
and  if,  at  any  time,  the  anaesthetic  effect  is  too  deep,  and  the  uterine 
action  is  in  consequence  impeded,  all  that  is  necessary  is  to  abstain 
entirely  from  exhibiting  the  chloroform  for  a short  time,  till  the 
parturient  contractions  have  been  allowed  to  come  back  to  their 
proper  degree  of  strength  and  frequency ; and  then  the  anaesthetic 
agency  is  to  be  sustained  as  before,  by  giving  the  vapour  with  every 
recurring  pain,  but  in  smaller  doses,  or  for  a shorter  time  during 
each  pain,  than  was  previously  practised. 


ADMINISTRATION  OF  CHLOROFORM. 


203 


Anaesthetic  vapours,  when  given  in  large  doses,  have  less  power 
of  reining  up  the  action  of  the  uterus  in  the  last  than  in  the  first 
part  of  labour.  And  as  the  sensations  of  pain  become  more  agonis- 
ing as  the  head  is  distending  the  perineum,  and  passing  through  the 
vulva,  the  anaesthetic  state  usually  requires  to  be  then  rendered 
more  deep  and  complete  than  in  the  early  stages  of  the  process  ; 
and  in  most  patients  this  may  be  done  without  at  all  impeding  the 
rapidity  of  the  delivery.  Indeed,  in  many  women,  this  latter  part 
of  the  process  of  parturition  seems  to  be  accelerated  by  the  superin- 
duction of  anaesthesia  ; for  the  degree  of  relaxation  of  the  muscular 
structures  of  the  perineum  and  vaginal  orifice,  commonly  resulting 
from  it,  usually  more  than  compensates  for  any  diminution  of  uterine 
action  that  may  occur.  If  in  any  instance  it  proves  otherwise,  and 
the  depth  of  the  anaesthetic  state  interferes  too  much  with  the  par- 
turient contractions,  the  simple  remedy  is  the  one  I have  already 
mentioned — a diminution  in  the  state  of  anaesthesia,  so  as  to  allow 
a return  and  increase  of  the  expulsive  efforts  of  the  uterus. 

The  degree  and  depth  of  anaesthesia  which  differeilt  patients  are 
capable  of  bearing  without  the  irritability  and  contractions  of  the 
uterus  being  impeded,  appears  to  differ  greatly  in  different  persons. 
In  some,  a very  deep  state  will  still  leave  the  uterus  almost  or 
altogether  unaffected  ; in  others,  its  action  is  interrupted  by  a 
comparatively  slight  degree  of  the  anaesthetic  state.  It  is  this 
variability  which  at  first  forms  the  principal  difficulty  to  those  com- 
mencing the  use  of  chloroform  in  obstetric  practice.  But  experience 
and  care  will  soon  enable  any  attentive  observer  to  overcome  this 
apparent  obstacle,  and  to  adapt  the  dose  of  the  agent  to  the  powers 
and  capabilities  of  each  different  patient.  I have  never  yet  seen  an 
instance,  but  I can  conceive  it  possible,  that  in  some  rare  exceptional 
cases  and  idiosyncrasies,  the  action  of  the  ether  or  chloroform  should, 
even  in  such  small  doses  as  merely  produce  unconsciousness  to  pain, 
interfere,  especially  in  the  first  stage  of  labour,  too  much  with  the 
muscular  action  of  the  uterus,  and  require  to  be  given  up,  at  least 
till  the  labour  be  more  advanced.  But  this  would,  of  course,  be  no 
reason  for  not  employing  it  on  those  other  persons  on  whom  it  had 
no  such  influence ; any  more  than  because  opium  occasionally  does 
not  act  as  an  hypnotic  on  particular  patients,  it  should  not  be  given 
with  that  indication  to  any  other  patients  with  the  view  of  inducing 
sleep. 

During  the  anaesthetic  sleep  which  chloroform  induces  in  natural 
labour,  the  patient  usually  lies  perfectly  quiet  and  passive  in  tlie  • 


204 


APPLICATIONS  IN  MIDWIFERY. 


intervals  between  the  pains,  but  moves  more  or  less,  and  sometimes 
moans,  as  each  uterine  contraction  begins  to  return.  In  the  last 
stage  she  generally,  with  every  recurring  uterine  contraction,  makes 
the  usual  violent  bearing-down  muscular  efforts,  and  the  struggle 
can  often  be  marked  in  the  expressions  of  her  face.  The  muscular 
action  of  the  uterus  and  assistant  mxuscles  goes  on,  and  yet  she  re- 
mains quite  unconscious.  The  strictest  quietude  should  always  be 
observed  and  enforced  around  the  patient,  for  noises  and  speaking, 
particularly  soon  after  the  chloroform  is  commenced,  will  sometimes 
excite  and  make  her  talk ; and,  if  this  happen,  we  may  require  to 
exhibit  to  her  a deeper  dose  than  would  otherwise  be  at  all  neces- 
sary. One  or  two  practitioners  of  midwifery  in  London  have 
averred  and  repeated,  over  and  over  again,  in  our  medical  journals, 
and  in  pamphlets  intended  for  non-medical  readers,  that  obstetric 
patients,  under  the  influence  of  chloroform,  must  be  liable  to  talk 
and  act  grossly  and  obscenely.  This  objection  to  the  practice  of 
anaesthesia  in  midwifery  has  been  repeated  and  gloated  over  by 
those  who  have  propounded  it,  in  a way  which  forms,  apparently 
unconsciously  on  their  own  part,  the  severest  self-inflicted  censure 
upon  the  sensuality  of  their  own  thoughts.  An  impure  mind,  more 
especially  in  a professional  man,  may  easily  fancy  and  find  impurities 
where  none  whatever  exist ; but  he  is  not  on  that  account  entitled 
to  irnagine  that  his  own  lewd  thoughts  are  typified  in  the  thoughts 
or  actions  of  his  patients.  In  answer  to  the  supposed  objection 
itself,  I have  merely  to  observe,  that  I never  once  witnessed  any 
trace  of  indecency,  either  in  word  or  action,  in  any  obstetric  patient 
under  the  use  of  chloroform  ; and  the  evidence  of  one  and  all  of  my 
obstetric  brethren,  of  whom  I h^ve  inquired  on  the  subject  here,  is 
to  the  same  effect.  In  a paper  on  temporary  delirium  occurring  in 
the  course  of  labour.  Dr.  Montgomery  several  years  ago  described 
more  marked  instances  of  effects  of  this  description,  arising  merely 
from  “the  extreme  distress  and  pain,”  to  which  the  mother  was 
subjected  in  the  dilatation  of  the  os  uteri,  etc.,  during  natural  par- 
turition, than  were  ever  seen  to  arise  from  the  influence  of  means 
used  to  abate  and  abrogate  that  “ extreme  distress  and  pain.” 

In  administering  chloroform  in  obstetric  practice,  I have  always 
used  the  handkerchief,  as  the  simplest  and  best  apparatus.  Some- 
times, when  the  case  is  likely  to  be  tedious,  I have  it  folded  and 
sewed  into  the  form  of  a deep  cup  or  cone.  The  chloroform  is 
j)oured  into  the  bottom  of  the  cup,  the  open  end  of  it  held  over  the 
' nose  and  mouth  of  the  patient  when  the  action  of  the  vapour  is 


ADMINISTRATION  OF  CHLOROFORM. 


205 


required  ; and,  when  its  application  is  suspended,  by  closing  the 
open  end  of  the  cone,  the  escape  and  loss  of  the  vapour  is  prevented 
during  the  intervals.  Such  an  arrangement  saves  the  chloroform. 
But  a handkerchief  merely  folded  together  and  sprinkled  with 
chloroform  answers  quite  well ; and  in  the  intervals  it  may  be  com- 
pressed together  in  the  hand,  so  as  to  prevent  the  escape  of  the  chlo- 
roform. In  first  throwing  the  patient  over  into  the  ana3Sthetic  sleep 
— (the  point  which  requires  the  most  management) — a handkerchief, 
thus  presenting  a large  surface,  is  often  much  more  serviceable  than 
one  folded  into  a cup  shape  ; for  the  patient,  when  first  coming 
under  the  influence  of  the  chloroform,  is  apt  to  move  her  head  from 
side  to  side  ; and,  in  order  to  keep  up  the  constant  inspiration  of 
the  vapour,  she  can  be  more  easily  followed  by  using  a simple  hand- 
kerchief, than  by  trying  to  keep  any  kind  of  apparatus  applied  to 
her  mouth  or  face. 

The  quantity  of  chloroform  used  varies  both  according  to  the 
duration  of  the  labour,’  ^nd  the  susceptibility  of  the  patient. 
Usually,  when  the  handkerchief  is  used,  about  an  ounce  an  hour  is 
necessary — a small  quantity  being  poured  upon  it  from  time  to 
time.  A less  dose  will  suffice  in  some,  and  others  require  more.  In 
one  case  lately,  where  the  patient,  in  a first  labour,  was  anaesthetised 
for  two  hours,  I expended  nearly  six  ounces,  large  doses  being 
necessary  to  keep  her  in  a sufficiently  deep  state  of  unconsciousness. 
The  first  quantity  which  I pour  on  usually  amounts  to  three  or  four 
drachms ; but  I always  judge  by  the  efifects^  not  by  measuring  the 
dose ; and  I pour  on  an  additional  quantity  in  a minute  or  so,  if  it 
be  required.  In  holding  the  handkerchief  towards  the  patient,  I 
take  care  that  plenty  of  atmospheric  air  is  admitted,  and  seldom  or 
never  put  it  in  contact  with  the  face.  At  first,  it  is  better  to  hold  it 
at  a considerable  distance,  in  order  to  prevent  any  chance  of  irrita- 
tion and  coughing ; and  then  gradually  approach  it.  It  is  always 
to  be  remembered  that  the  vapour  of  chloroform  is  nearly  four  times 
the  specific  gravity  of  atmospheric  air  ; and  if  the  patient  is  lying 
on  her  side,  the  handkerchief  or  pillow  can  be  easily  arranged  so  as 
to  keep  a larger  supply  of  this  heavy  vapour  opposite  the  mouth  and 
nostrils.  I have  always  held  and  managed  the  handkerchief  myself 
in  the  first  instance,  and  till  the  patient  was  asleep.  Afterwards,  I 
have  generally  trusted  it  to  the  husband  or  nurse,  teaching  them  to 
apply  it  near  the  face  when  the  pains  supervened,  and  to  fold  up 
the  handkerchief  in  the  way  mentioned,  so  as  to  preserve  the  chloro- 
form during  the  intervals. 


206 


APPLICATIONS  IN  MIDWIFERY. 


When  exhibiting  chloroform  in  obstetric  practice,  and  in  the 
way  I have  described,  I have  often  been  struck  by  the  circumstance 
that  its  use  is  very  rarely  followed  by  sickness  or  vomiting.  I do 
not  remember  having  seen  vomiting  follow  its  exhibition  during 
labour  in  more  than  four  or  five  cases,  and  two  of  these,  in  the 
practice  of  Dr.  Paterson  and  Dr.  Cochrane,  were  instances  in  which 
1 was  called  in  to  apply  the  forceps,  and  where  the  patients  were 
placed  for  the  operation  in  a state  of  anaesthesia  as  deep  as  that 
used  in  surgery.  I have  repeatedly  seen  it  arrest  the  sickness  and 
vomiting  occasionally  accompanying  the  first  stage  of  labour. 

In  addition,  let  me  state  that  I have  usually  begun  the  employ- 
ment of  the  chloroform  when  the  os  uteri  was  well  dilated,  or 
towards  the  termination  of  the  first  and  the  commencement  of  the 
second  stage  of  the  labour.  But  when  the  pains  were  severe  I have 
commenced  it  earlier,  and  when  the  os  uteri  was  still  comparatively 
little  dilated.  There  is,  I believe,  no  limit  as  to  the  date  of  the 
labour  at  which  we  may  give  it. 


The  rules  for  the  exhibition  of  chloroform  in  parturition  may  be 
summarised  as  follows  : — 

1.  Begin  the  inhalation  of  chloroform  when  the  patient  complains 
of  much  pain.  This  is  generally  towards  the  end  of  the  first  stage. 

2.  Always  inculcate  perfect  quietness  around  the  patient,  par- 
ticularly when  commencing  to  give  the  chloroform. 

3.  Oyily  give  it  during  the  pains,  and  withdraw  it  during  the 
intervals. 

Exceptions. — Give  a whiff  of  the  chloroform  also  during  the  inter- 
vals when  the  pains  are  very  severe,  and  the  patient  awakes  com- 
plaining of  them. 

Give  small  doses,  or  only  repeat  them  every  second  or  third 
pain,  when  the  chloroform  affects  the  action  of  the  heart  and  uterus. 
These  cases  are  very  rare. 

4.  When  given  during  the  first  stage  the  anaesthesia  need  not 
be  deep,  unless  the  suffering  be  great  or  the  symptoms  of  anaesthesia 
disagreeable. 

5.  As  the  second  stage  progresses,  make  the  anaesthesia  so  com- 
plete as  to  destroy  all  sensibility. 

6.  Do  not  allow  the  urinary  bladder  to  become  over  distended. 

7.  Do  not  restrain  the  patient  in  one  position. 

8.  Be  sure  to  remove  the  chloroform  as  soon  as  the  child  is  born. 

9.  Do  not  awake  the  patient  artificially. 


ILLUSTKATIVE  CASES. 


207 


CHAPTER  III. 

CASES  ILLUSTRATIVE  OF  THE  USE  AND  EFFECTS  OF  CHLOROFORM 
IN  MIDWIFERY. 

Edinburgh,  November  1847. 

I HAVE  not  yet  had  an  opportunity  of  using  chloroform  in  any 
capital  surgical  operation,  hut  have  exhibited  it  with  perfect  success 
in  tooth-drawing, ‘ opening  abscesses,  for  annulling  the  pain  of  dys- 
menorrheea,  and  of  neuralgia,  and  in  two  or  three  cases  where  I was 
using  deep,  and  otherwise  very  painful  galvano-puncture  for  the 
treatment  of  ovarian  dropsy,  etc.  I have  employed  it  also  in 
obstetric  practice  with  entire  success. 

Case  I. — The  lady  to  whom  it  was  first  exhibited  during  parturition  had 
been  previously  delivered  in  the  country  by  perforation  of  the  head  of  the  infant, 
after  a labour  of  three  days’  duration.  In  this,  her  second  confinement,  pains 
supervened  a fortnight  before  the  full  time.  Three  hours  and  a half  after  they 
commenced,  and  ere  the  first  stage  of  the  labour  was  completed,  I placed  her 
under  the  influence  of  the  chloroform,  by  moistening,  with  half  a teaspoonful  of 
the  liquid,  a pocket-handkerchief,  rolled  up  into  a funnel  shape,  and  with  the 
broad  or  open  end  of  the  funnel  placed  over  her  mouth  and  nostrils.  In  conse- 
quence of  the  evaporation  of  the  fluid,  it  was  once  more  renewed  in  about  ten  or 
twelve  minutes.  The  child  was  expelled  in  about  twenty-five  minutes  after  the 
inhalation  was  begun.  The  mother  subsequently  remained  longer  soporose  than 


^ A young  dentist  who  has  himself  had  two  teeth  extracted  lately — one  under 
the  influence  of  ether,  and  the  other  under  the  influence  of  chloroform — writes  me 
the  following  statement  of  the  results  : — “About  six  months  ago  1 had  an  upper 
molar  tooth  extracted  whilst  under  the  influence  of  ether,  by  Mr.  Imlach.  The 
inhalation  was  continued  for  several  minutes  before  I presented  the  usual  appear- 
ance of  complete  etherisation  ; the  tooth  was  then  extracted  ; and  although  I did 
not  feel  the  least  pain,  yet  I was  conscious  of  the  operation  being  performed,  and 
was  quite  aware  when  the  crash  took  place.  Some  days  Ago  1 required  another 
molar  extracted  on  account  of  toothache,  and  this  operation  was  again  performed 
by  the  same  gentleman.  I inhaled  the  vapour  of  chloroform,  half  a drachm  being 
poured  upon  a handkerchief  for  that  purpose,  and  held  to  my  nose  and  mouth. 
Insensibility  took  place  in  a few  seconds  ; but  I was  so  completely  dead  this  time, 
that  I was  not  in  the  very  slightest  degree  aware  of  anything  'that  took  place. 
The  subsequent  stupifying  effects  of  the  chloroform  went  off  more  rapidly  than 
those  of  the  ether  ; and  I was  perfectly  well  and  able  again  for  my  work  in  a few 
minutes.  ” 


208 


APPLICATIONS  IN  MIDWIFERY. 


commonly  happens  after  ether.  The  squalling  of  the  child  did  not,  as  usual, 
rouse  her ; and  some  minutes  elapsed  after  the  placenta  was  expelled,  and  after 
the  child  was  removed  by  the  nurse  into  another  room,  before  the  patient  awoke. 
She  then  turned  round  and  observed  to  me  that  she  had  “enjoyed  a very  com- 
fortable sleep,  and  indeed  required  it  as  she  was  so  tired,  ^ but  would  now  be  more 
able  for  the  work  before  her.”  I evaded  entering  into  conversation  with  her, 
believing,  as  I have  already  stated,  that  the  most  complete  possible  quietude  forms 
one  of  the  principal  secrets  for  the  successful  employment  of  either  ether  or  chloro- 
form. In  a little  time  she  again  remarked  that  she  was  afraid  her  “sleep  had 
stopped  the  pains.”  Shortly  afterwards,  her  infant  was  brought  in  by  the  nurse 
from  the  adjoining  room,  and  it  was  a matter  of  no  small  difficulty  to  convince 
the  astonished  mother  that  the  labour  was  entirely  over,  and  that  the  child  pre- 
sented to  her  was  really  her  “own  living  baby.” 

Edinburgh,  December  1847. 

Case  II. — I exhibited  it,  with  Mr.  Carmichael,  to  a patient  who  had,  at  her 
preceding  confinement,  been  in  severe  labour  for  twenty  hours,  followed  by  flood- 
ing. She  began  the  inhalation  when  the  dilatation  of  the  os'uteri  was  half  com- 
pleted. The  child  was  born  in  fifty  minutes  afterwards.  She  was  kept  under  its 
influence  for  a quarter  of  an  hour  longer,  till  the  placenta  was  removed,  and  the 
binder,  body  and  bed  clothes,  all  adjusted.  On  awaking,  she  declared  she  had 
been  sleeping  refreshingly  ; and  was  quite  unconscious  that  the  child  was  born 
till  she  suddenly  heard  it  squalling  at  its  first  toilet  in  the  next  room.  No 
flooding.  An  hour  afterwards,  she  declared  she  felt  perfectly  unfatigued,  and  not 
as  if  she  had  borne  a child  at  all. 

Case  III. — Patient  unmarried.  A first  labour.  Twins.  The  first  child  pre- 
sented by  the  pelvis,  the  second  with  the  hand  and  head.  The  chloroform  was 
exhibited  when  the  os  uteri  was  nearly  fully  dilated.  The  passages  speedily 
became  greatly  relaxed,  as  has  happened  in  other  cases  placed  under  its  full 
influence  ; and  in  a few  pains  the  first  child  was  born,  assisted  by  some  traction. 
I broke  the  membranes  of  the  second,  pushed  up  the  hand,  and  secured  the  more 
complete  presentation  of  the  head.  Three  pains  expelled  the  child.  The  mother 
was  then  bound  up  ; her  clothes  were  changed,  and  she  was  lifted  into  another 
bed.  During  all  this  time  she  slept  on  soundly,  and  for  a full  hour  afterwards  ; 
the  chloroform  acting  in  this,  as  in  other  cases  of  its  prolonged  employment,  as  a 
soporific.  The  patient  recollected  nothing  from  the  time  of  the  first  inhalations  ; 
and  was  in  no  small  degree  distressed  when  not  one — but  two — living  children 
were  brought  by  the  nurse  to  her.  Dr.  Christison  accompanied  me  to  this  case. 

Case  IV. — Primipara  of  full  habit.  When  the  first  examination  was  made, 
the  passages  were  rigid,  and  the  os  uteri  difficult  to  reach.  Between  six  and  seven 
hours  after  labour  began,  the  patient,  who  w’as  complaining  much,  was  apathised 
with  chloroform.  In  about  two  hours  afterwards  the  os  uteri  was  fully  dilated, 
and  in  four  hours  and  ja  half  after  the  inhalation  was  begun,  a large  child  was 
expelled.  The  placenta  was  removed,  and  the  patient  bound  up  and  dressed 
before  she  was  allowed  to  a^vake.  This  patient  required  an  unusual  quantity  of 
chloroform  ; and  Dr.  Williamson,  who  remained  beside  her,  states  to  me,  in  his 
notes  of  the  case,  “ the  handkerchief  was  moistened  often  in  order  to  keep  up  the 


1 In  consequence  of  extreme  anxiety  at  the  unfortunate  result  of  her  previous 
confinement,  she  had  slept  little  or  none  for  one  or  two  nights  preceding  the  com- 
mencement of  her  present  accouchement. 


ILLUSTRATIVE  CASES. 


209 


soporific  effect.  On  one  occasion  I allowed  her  to  emerge  from  this  state  for  a 
short  time  ; but  on  the  accession  of  the  first  pain  she  called  out  so  for  the  chloro- 
form, that  it  was  necessary  to  pacify  her  by  giving  her  some  immediately.  In 
all,  four  ounces  of  chloroform  were  used.”  Like^the  others,  she  was  quite  un- 
conscious of  what  had  gone  on  during  her  anaesthetic  state  ; and  awoke  altogether 
unaware  that  her  child  was  born. 

Case  V. — Second  labour.  This  patient,  after  being  several  hours  in  labour, 
was  brought  to  the  Maternity  Hospital.  I saw  her  some  time  afterwards,  and 
found  the  first  stage  protracted  by  the  right  side  of  the  cervix  uteri  being  thick, 
oedematous,  and  undilatable.  The  inhalation  of  chloroform  was  begun,  and  the 
first  stage  was  terminated  in  about  a couple  of  hours.  Two  or  tliree  pains  drove 
the  child  through  the  pelvic  canal,  and  completed  the  second  stage.  Fifteen 
minutes  in  all  elapsed  from  the  terjnination  of  the  first  to  the  termination  of  the 
third  stage,  or  the  expulsion  of  the  placenta.  The  patient  was  dressed  and  re- 
moved into  a dry  bed,  where  she  slept  on  for  a short  time  before  awaking,  and 
being  conscious  of  her  delivery. 

Case  VI. — Second  labour.  The  patient,  a person  of  small  form  and  delicate 
constitution,  bore  her  first  child  prematurely,  at  the  seventh  month.  After 
being  six  hours  in  labour,  the  os  uteri  was  fully  expanded,  and  the  head  well 
down  in  the  pelvic  cavity.  For  two  hours  subsequently  it  remained  fixed  in 
nearly  the  same  position,  and  scarcely  if  at  all  advanced,  although  the  pains  were 
very  distressing,  and  the  patient  becoming  faint  and  exhausted.  Slie  entertained 
some  mistaken  religious  feelings  against  ether  or  chloroform,  which  had  made 
her  object  to  the  earlier  use  of  the  latter  ; but  I now  placed  her  under  its  influence. 
She  lay  as  usual  like  a person  soundly  asleep  under  it,  and  I was  now  able,  with- 
out any  suffering  on  her  part,  to  increase  the  intensity  and  force  of  each  recur- 
ring pain,  by  exciting  the  uterus  and  abdominal  muscles  through  pressure  on  the 
lower  part  of  the  vagina  and  perineum.  The  child  was  expelled  in  about  fifteen 
minutes  after  the  inhalation  was  commenced.  In  a few  minutes  she  awoke  to  ask 
if  it  was  really  possible  that  her  child  had  been  born  ; and  was  overjoyed  to  be 
told  that  it  was  so.  I had  the  conviction  that  in  this  case  the  forceps  would  in 
all  probability  have  been  ultimately  required,  perhaps  hours  subsequently,  pro- 
vided I had  not  been  able  to  have  interfered  in  the  way  mentioned.  I might,  it 
is  true,  have  followed  the  same  proceeding  though  the  patient  was  not  in  an 
anaesthetic  .state,  but  I could  not  have  done  so  without  inflicting  great  misery 
and  agony  upon  her,  and  meeting  with  great  resistance. 

Case  VII. — A third  labour.  The  patient  had  been  twice  before  confined  of 
dead  premature  children  ; once  of  twins,  under  the  care  of  Mr.  Stone  of  London  ; 
the  second  time  of  a single  child,  under  my  own  charge.  The  liquor  amnii  began 
to  escape  about  one  o’clock  A.]\r.,  but  no  pains  followed  for  some  time.  I saw 
her  between  three  and  four,  with  the  pains  commencing,  and  the  os  uteri  begin- 
ning to  dilate.  In  two  hours  afterwards  the  first  stage  was  well  advanced,  and, 
the  pains  becoming  severe,  she  had  the  chloroform  exhibited  to  her,  and  slept 
soundly  under  its  influence.  In  twenty  minutes  the  child  was  born,  and  cried 
very  loudly  without  rousing  the  mother.  In  about  twelve  or  fifteen  minutes  more 
she  awoke,  as  the  application  of  the  binder  was  going  on,  and  immediately  de- 
manded if  her  child  was  really  born  and  alive,  as  she  thought  she  had  some  recol- 
lection of  hearing  the  nurse  say  so.  She  was  rejoiced  beyond  measure  on  her  son 
being  brought  in  and  presented  to  her. 


210 


APPLICATIONS  IN  MIDWIFERY. 


Case  VIII. — Fourth  labour.  The  patient  had  borne  three  dead  children  pre- 
maturely, about  the  sixth  and  seventh  months  of  utero-gestation.  During  her 
present  pregnancy  I placed  her  under  strict  rules  and  discipline  ; and  she  used, 
Ifoin  an  early  period,  small  doses  of  chlorate  of  potass  several  times  a-day.  She 
carried  her  children  to  the  full  time.  Labour  came  on  about  one  o’clock  a.m. 
The  membranes  broke  at  eight  A.M.,  when  the  os  uteri  was  still  very  slightly 
open.  It  had  made  very  little  progress  at  ten  o’clock,  when  Dr.  Keith  exhibited 
the  chloroform  to  her.  The  pains  continued  very  strong  and  regular,  the  passages 
relaxed,  and  at  half-past  eleven  she  was  delivered  of  a large  living  child.  The 
placenta  came  away  immediately  ; and  she  was  bound  up,  and  her  soiled  clothes 
removed,  before  she  awoke.  She  remembered  nothing  whatever  that  had  occurred 
after  she  began  to  inhale  the  chloroform  till  the  period  of  her  awaking. 

The  preceding  instances  afford,  perhaps,  a sufficient  number  of 
examples  of  the  use  of  chloroform  in  natural  labour.  In  these  and 
in  all  others  which  I have  seen,  or  that  have  been  reported  to  me, 
the  immediate  effects  of  the  chloroform  have  been  delightful.  The 
mothers,  instead  of  crying  and  suffering  under  the  strong  agonies 
and  throes  of  labour,  have  lain  in  a state  of  quiet,  placid  slumber, 
made  miore  or  less  deep  at  the  will  of  the  medical  attendant,  and, 
if  disturbed  at  all,  disturbed  only  unconsciously  from  time  to  time 
by  the  recurring  uterine  contractions  producing  some  reflex  or 
automatic  movements  on  the  part  of  the  patient — like  those  of  a 
person  moving  under  any  irritation  of  the  surface,  or  from  the  touch 
of  another,  though  still  in  a state  of  sleep.  Nor  have  the  ultimate 
consequences  and  results  been  less  happy.  No  difficulties  have 
been  met  with  in  the  third  stage ; and  the  uterus  has  contracted 
perfectly  after  delivery.  I never  saw  mothers  recover  more  satis- 
factory or  rapidly — or  children  that  looked  more  viable.  And  the 
practice  is  not  a great  blessing  to  the  patient  merely  ; it  is  a great 
boon  also  to  the  practitioner.  For  whilst  it  relieves  the  former 
from  the  dread  and  endurance  of  agony  and  pain,  it  both  relieves 
the  latter  from  the  disagreeable  necessity  of  witnessing  such  agony 
and  pain  in  a fellow-creature,  and  imparts  to  him  the  proud  power 
of  being  able  to  cancel  and  remove  pangs  and  torture  that  would 
otherwise  be  inevitable.  It  transforms  a work  of  physical  anguish 
into  one  of  painless  muscular  effort ; and  changes  into  a scene  of 
sleep  and  comparative  repose,  that  anxious  hour  of  female  existence, 
which  has  ever  been  proverbially  cited  as  the  hour  of  the  greatest 
of  mortal  suffering. 

The  effects  of  the  superinduction  of  anaesthesia  in  parturition 
are,  if  possible,  still  more  marked  and  beneficial  in  cases  of  morbid 
labour  and  operative  delivery.  In  proof  of  its  influence  in  this 


ILLUSTRATIVE  CASES. 


211 


respect,  I shall  cite  some  examples  of  its  employment  in  cases  of 
turning,  of  the  application  of  the  forceps,  and  of  embryulsio. 

Case  IX. — Fourth  labour.  The  mother  deformed,  and  the  conjugate  diameter 
of  the  brim  of  the  pelvis  contracted  from  the  projection  inwards  and  forwards  of 
the  promontory  of  the  sacrum.  Her  first  child  was  delivered  by  embryulsio  ; the 
second  by  the  long  forceps  ; the  third  was  small,  and  passed  Avithout  artificial 
assistance.  On  the  present  occasion,  after  suffering  slight  pains  during  the  whole 
night,  labour  set  in  Avith  greater  severity  towards  morning.  After  being  in 
strong  labour  for  some  hours,  she  Av^as  seen  first  by  Mr.  Figg,  and  afterwards  by 
Dr.  Peddie,  her  ordinary  medical  attendant.  I was  called  to  her  about  four 
o’clock  P.M.  The  pains  Avere  then  enormously  poAverful  and  straining,  imparting 
to  the  mind  the  dread  of  the  uterus  rupturing  under  their  influence  ; but  the 
head  of  the  child  Avas  still  altogether  above  the  brim,  and  only  an  oedematous 
ridge  of  the  scalp  pressed  through  the  superior  and  contracted  pelvic  opening. 
The  passages  had  become  heated,  the  mother’s  pulse  raised,  etc.,  and  Dr.  Peddie 
had  tried  tAvo  different  pairs  of  long  forceps.  After  I arrived,  he  applied  Avith 
great  skill  another  pair  of  long  forceps  which  I had  Avith  me  ; but  it  Avas  found 
impossible  to  move  the  head  in  the  least  degree  forAvards.  The  urgency  and 
power  of  the  uterine  contractions,  the  immobility  of  the  head  upon  the  brim  of 
a deformed  pelvis,  and  the  state  of  the  patient  and  of  the  parts,  all  shoAved  the 
necessity  of  relief  being  obtained  by  artificial  delivery.  In  her  first  labour 
I had  assisted  Dr.  Peddie  in  delivering  her  under  similar  circumstances  by 
perforation  of  the  head.  But  here  the  child’s  heart  Avas  heard  distinctly  Avith  the 
stethoscope,  and  he  at  once  agreed  to  my  proposition,  that  I should  try  to  deliver 
her  by  turning  the  infant — compressing  and  indenting  the  flexible  skull  of  the 
foetus,  instead  of  perforating  it,  and  thus  affording,  as  I have  for  some  time  past 
taught  and  believed,  some  chance  of  life  to  the  child,  and  more  chance  of  safety 
to  the  mother.  The  patient  was  placed  under  the  influence  of  chloroform  still 
more  deeply  than  Avhen  the  forceps  Avere  used,  in  order,  if  possible,  entirely  to 
arrest  the  uterine  contractions.  I passed  up  my  hand  into  the  uterus,  seized  a 
knee,  and  easily  turned  the  infant ; but  very  great  exertion  and  jjulling  Avas 
required  to  extract  the  child’s  head  through  the  distorted  brim.  At  last  it  passed, 
much  compressed  and  elongated.  The  child  Avas  still-born,  but,  by  applying  the 
usual  restorative  means,  it  speedily  began  to  breathe  and  cry.  The  child  continues 
well,  and  the  mother  has  made  a rapid  recovery. 

Case  X. — In  the  Maternity  Hospital ; first  child.  Labour  began  at  ten  p.m. 
(21st  Nov.)  I Avas  desired  to  see  her  at  six  a.m.  (22d).  The  os  uteri  Avas  Avell 
dilated,  but  it  AA^as  evident  that  the  pelvic  canal  AA'as  contracted  throughout,  and 
the  head  Avas  passing  Avith  unusual  difficulty  through  the  brim.  The  patient  Avas 
complaining  much  of  her  sufferings.  It  Avas  clear  that  it  Avould  be  a very  tedious 
and  probably  at  last  an  instrumental  case,  and  one  therefore  calculated  to  test  the 
length  of  time  during  Avhich  chloroform  might  be  used.  She  began  to  inhale  it 
at  a quarter  past  six  A.  m.  , and  Avas  kept  under  its  influence  till  a quarter  past  seven 
P.M.,  the  date  of  her  delivery — thirteen  hours  in  all.  From  the  time  it  Avas  begun  to 
the  time  delivery  Avas  completed,  her  cries  and  complaints  ceased,  and  she  slept 
soundly  on  throughout  the  day.  The  bladder  required  to  be  emptied  several  times 
Avith  the  catheter.  The  head  passed  the  os  uteri  at  ten  a.  m.  ; and,  during  the  day, 
gradually  descended  through  the  pelvis.  At  seven  P.  M.  I at  last  deemed  it  proper  to 
deliA^er  her  by  the  forceps  ; the  head,  AAdiich  Avas  noAv  elongated  and  oedematous, 
haAdng  by  that  time  rested  for  some  hours  against  the  contracted  peh'ic  outlet 


212 


APPLICATIONS  IN  MIDWIFERY. 


with  little  or  no  evidence  of  advancement,  the  hones  of  the  foetal  cranium  over- 
lapping each  other  ; and  the  foetal  heart  becoming  less  strong  and  distinct  in  its 
pulsations.  A warm  lath,  irritation  of  the  chest,  etc.,  were  necessary  to  excite 
full  and  perfect  respiration  in  the  infant.  Whilst  w'e  were  all  busied  with  the 
infant,  the  mother  lost  some  blood  ; but  the  placenta  was  immediately  removed, 
and  the  uterus  contracted  perfectly.  On  afterwards  measuring  the  quantity  of 
blood  lost,  it  was  calculated  to  amount  to  15  or  18  ounces.  The  mother’s  clothes 
were  changed  ; she  w'as  bound  up  and  removed  to  a dry  bed  before  she  awoke. 
She  had  at  first  no  idea  that  the  child  was  born,  and  was  in  no  respect  conscious 
of  being  delivered.  In  fact,  she  had  been  “sleeping,”  according  to  her  own 
account,  from  the  time  she  had  begun  the  inhalation,  and  only  thought  she  once 
or  twice  remembered  or  dreamed  that  she  heard  Dr.  Williamson,  the  house-surgeon, 
speak  near  her.  Dr.  Beilby,  Dr.  Zeigler,  etc.,  saw  the  case  with  me.  The  mothe» 
and  child  have  continued  perfectly  well. 

In  this,  as  in  other  cases,  I have  watched  and  noted  the  effects 
of  the  chloroform  upon  the  duration  of  the  pains  and  of  the  inter- 
vals, the  rate  of  the  foetal  and  maternal  pulse,  etc. 

Case  XI. — Patient  with  a deformed  spine  and  contracted  pelvic  outlet.  At 
her  first  confinement  two  different  medical  gentlemen  had  failed  in  effecting  de- 
livery by  the  forceps.  At  this,  her  second  confinement,  she  placed  herself  under 
the  care  of  Dr.  Paterson  of  Leith.  After  being  very  long  in  labour,  and  the 
symptoms  of  the  case  becoming  urgent,'  I saw  her  with  Dr.  Paterson.  The  head 
was  low  down  in  the  pelvis  ; but  it  was  placed  in  the  right  occipito-posterior  posi- 
tion (the  third  of  Naegele),  and  the  forehead  instead  of  the  vertex  was  presenting, 
one  orbit  being  easily  felt  behind  the  symphysis  pubis.  It  had  been  lodged  in 
nearly  the  same  position  for  many  hours.  The  foetal  heart  was  still  distinct,  but 
weak.  I applied  the  forceps,  turned  the  head  round  with  them  a quarter  of  a 
circle,  into  an  occipito-anterior  position  (the  second  of  Naegele)  ; and,  after  being 
so  adjusted,  it  still  required  considerable  force  to  extract  it.  Before  applying  the 
forceps,  the  patient  was  sent  into  a state  of  deep  anaesthesia  by  the  inhalation  of 
chloroform  ; and  subsequently,  when  she  awakened  out  of  it,  she  was  in  no  small 
degree  surprised  to  find  that  she  had  really  been  delivered  while  she  was  sleeping 
and  resting  so  soundly.  The  placenta  separated,  and  the  uterus  contracted 
firmly.  The  child,  which  was  large,  lived  for  eight  hours  after  delivery  ; but, 
despite  of  all  the  measures  tried,  full  and  perfect  respiration  was  never  established 
in  it — apparently  in  consequence  of  some  effusion  or  injury  about  the  base  of  the 
brain.  Unfortunately  a post-mortem  examination  was  not  obtained.  The 
mother  has  made  an  excellent  recover}". 

I quote  the  following  instance  of  craniotomy  under  chloroform 
from  a letter  (dated  29th  November)  which  I have  received  from 
my  friend  Professor  Murphy  of  London.  I give  the  case  in  Dr. 
Murphy’s  own  words. 

Case  XII. — “I  have  tried  the  chloroform  with  great  success  in  a case  of  dis- 
torted pelvis.  It  was  the  ovate  deformity,  the  conjugate  measurement  being  only 
two  and  a half  inches  ; the  head  of  the  child  could  not  enter  the  brim,  and  I was 
obliged  to  perforate.  I got  Dr.  Snow  to  assist  me  in  bringing  her  under  the  in- 
fluence of  chloroform.  She  made  some  resistance,  and  struggled  a good  deal  at 
first,  chiefly,  I think,  from  apprehension  that  we  were  going  to  do  something 


ILLUSTRATIVE  CASES. 


213 


very  dreadful ; however,  she  soon  began  to  inhale  quietly,  and  gradually  fell  into 
a kind  of  dreamy  sleep.  I perforated  the  head,  and  laboured  with  the  crotchet, 
sornetimes  with  the  craniotomy  forceps,  for  three  quarters  of  an  hour  before  I 
could  get  the  head  through  the  brim.  She  was  at  length  delivered  ; the  placenta 
was  separated  in  about  ten  minutes,  the  bandage  applied,  soiled  clothes  removed, 
and  she  was  made  clean  and  comfortable  as  the  midwives  say.  My  patient  was 
perfectly  unconscious  all  this  time,  and  did  not  awake  for  about  a quarter  of  an 
hour  after  the  operation  ; she  did  so  then  quite  quietly,  and  was  greatly  surprised 
to  find  that  all  her  miseries  were  over.  There  was  no  hemorrhage  ; but  the  uterus 
felt  rather  spongy  and  large.  She  is  now  recovering  most  favourably.  I never 
had  a case  recover  so  far  so  well.” 


214 


APPLICATIONS  IN  MIDWIFERY. 


CHAPTER  IT. 

REPORT  OF  THE  RESULTS  OF  ANESTHESIA  FROM  DIFFERENT 
OBSTETRIC  HOSPITALS  AND  PRACTITIONERS. 

Edinburgh,  October  1848. 

The  following  account  of  the  results  of  anaesthesia  in  the  practice 
of  the  Maternity  Hospital,  Edinburgh,  has  been  drawn  up  by  Dr. 
Duncan  and  Mr.  Norris,  two  gentlemen  who  have  acted  as  resident 
house-surgeons  in  the  institution,  and  upon  whose  power  and  ac- 
curacy of  observation  all  who  are  acquainted  with  them  will  place 
implicit  reliance : — 

“ Since  the  use  of  anaesthesia  in  labour  became  general  in  the 
Maternity  Hospital,  shortly  after  the  discovery  of  chloroform,  95 
women  in  all  have  been  delivered  in  the  house  under  its  influence. 
Among  these,  88  were  natural,  and  7 were  morbid  labours.  In  the 
88  cases  of  natural  delivery,  only  one  of  the  mothers  died,  convul- 
sions coming  on  five  hours  after  delivery,  and  proving  fatal  after  a 
continuance  of  six  days.  On  a yost  mortem  examination,  the  kidneys 
were  found  to  have  undergone,  in  some  parts,  the  true  stearoid 
degeneration.^  Among  the  same  88  cases  of  natural  labour,  there 
were  5 dead-born  children.  In  two  of  these  cases,  the  birth  was 
premature,  being  at  the  sixth  month.  In  the  third  case,  the  mother 
had  previously  given  birth  to  two  dead  infants.  The  fourth  dead 
child  had  a very  large  hydrocephalic  head.  The  proportion  of  still- 
born children  was  thus  1 in  17.  In  the  Dublin  Hospital  the  pro- 
portion of  still-born  children,  as  reported  some  years  ago  by  Dr. 
Collins,  was  1 in  15.  The  7 instrumental  cases  were  as  follows : — 
One  application  of  the  short  forceps,  in  an  unsuccessful  attempt  to 
save  the  life  of  the  child  ; the  mother  recovered  well ; — two  cases  in 
which  the  long  forceps  were  applied ; one  of  the  women,  in  whom 
the  head  was  very  long  impacted  in  the  pelvic  brim,  died  from 
sloughing  of  the  maternal  passages ; the  other  made  a good  re- 

^ See  a report  of  the  Monthly  Journal  for  September,  p.  196. 


OPINIONS  OF  PEACTITIONEPS. 


215 


covery  ; both  the  children  were  born  alive  ; — four  cases  of  version  ; 
one  of  the  mothers  died  from  rupture  of  the  uterus,  the  others 
recovered  quickly ; three  of  the  children  were  still-born,  and  in  one 
of  these  three  cases  the  cord  was  prolapsed. 

“ In  addition  to  these  88  cases  of  anaesthetic  delivery,  there  have 
been  upwards  of  fifty  women  delivered  in  the  house  without  chloro- 
form. Tliese  have  been  chiefly  very  rapid  labours,  where  the  women 
have  come  into  the  hospital  just  in  time  to  give  birth  to  their  in- 
fants, or  where  the  house-surgeon  has  not  been  able  to  see  them  till 
very  shortly  before  delivery.  From  the  expense  attending  a large 
consumption  of  chloroform,  it  has  always  been  an  object  to  husband 
it  as  much  as  possible;^  and  therefore,  in  the  hospital,  it  has  not 
been  given  in  cases  where  the  mothers  did  not  very  severely  com- 
plain of  their  sufferings,  nor  were  harassed  with  feelings  of  anxiety 
and  fear. 

“ On  the  whole,  the  results  of  anajsthetic  midwifery,  as  observed 
by  us  in  the  hospital,  have  been  perfectly  satisfactory ; and  we  can 
confidently  state  that  the  recoveries  have  been  altogether  more  per- 
fect and  speedy  than  before.  This  has  been  remarked  in  so  great 
a proportion  of  the  cases,  that  there  can  be  no  doubt  whatever  of  the 
truth  of  the  observation.  Besides  the  increased  rapidity  of  recovery, 
we  have  noticed  the  almost  entire  absence  of  those  uncomfortable 
feelings  of  fatigue,  languor,  and  shivering,  and  of  that  shattered 
feeling  which  so  frequently  comes  upon  the  mother  immediately 
after  an  ordinary  delivery.  Instead  of  this,  we  have  found  the 
mother  almost  invariably  awake  from  the  ancesthetic  sleep  com- 
paratively fresh,  easy,  and  cheerful.  Kot  unfrequently  the  anaes- 
thetic has  been  found  to  change,  without  an  intermission,  into  a 
natural  sleep,  which  may  continue  for  an  hour  or  two. 

“ Further,  there  have  been,  since  the  introduction  of  chloroform 
“into  the  practice  of  the  hospital,  far  fewer  than  formerly  of  those 
violent  attacks  of  rigors,  ephemeral  fevers  or  weeds,  and  abdominal 
pains,  which  are  so  common  in  most  crowded  hospitals,  forming  a 
class  of  cases  which  used  formerly  to  cause  much  anxiety,  and  was 
a common  cause  of  the  mother’s  being  detained  in  the  hospital  after 

^ Perhaps,  in  a short  time,  a benevolent  government  will  allow  chloroform  to 
be  made  cheaper,  by  removing  the  very  high  duty  on  proof  spirit  Avhen  used  for 
medical  and  chemical  purposes  (tinctures,  etc.)  At  present  that  high  duty  is,  in 
one  respect,  a direct  tax  upon  the  relief  of  human  disease,  and  the  mitigation  of 
human  pain  ; and  a great  obstacle  to  the  progress  of  British  organic  chemistry. 
See  also  p.  173. 


216 


APPLICATIONS  IN  MIDWIFERY. 


the  usual  fortnight  allowed  for  recovery.  In  fact,  since  using  chloro- 
form, there  have  been  scarcely  any  women  detained  in  the  house  by 
these  causes,  and  much  less  Dover’s  powder,  calomel  and  opium, 
abdominal  fomentations,  etc.,  have  been  used. 

“The  women  have  been,  invariably,  found  deeply  grateful  for 
the  relief  to  their  sufferings  afforded  by  the  anaesthetic  influence  of 
chloroform. — Yours,  etc.,  J.  M.  Duncan.  H.  Norris.” 

At  a meeting  of  the  Edinburgh  Medico-Chirurgical  Society  in 
June  last,  along  with  other  practitioners,  I gave  in  a report  on  the 
employment  of  chloroform  in  midwifery.  At  that  time,  and  since, 
I have  been  favoured  with  written  statements  of  the  results,  by 
various  medical  friends  in  Edinburgh,  and  in  different  parts  of  the 
country.  I shall  now  give  extracts  from  a variety  of  the  letters 
Avhich  I have  received,  relative  to  this  subject.  Many  more  such 
communications  might  easily  have  been  called  up  and  adduced  ; but 
I have  deemed  it  useless  to  multiply  unnecessarily  this  kind  of 
evidence.  It  will  be  observed  that,  with  one  exception  (see  the 
connm unication  of  Mr.  Lansdowne),  the  following  letters  refer,  like 
the  preceding  statements  regarding  the  Maternity  Hospital,  to  the 
use  of  chloroform  alone. 

The  first  statement  which  I give  is  from  my  assistant  and  friend. 
Dr.  Keith. 

“ I have  employed  chloroform  in  every  case  of  labour  under  my 
care  since  its  introduction,  with  one  exception ; and  also  in  almost 
every  case  to  which  I have  been  called  in  by  other  practitioners. 
In  my  own  cases,  amounting  to  about  four-and-twenty,  it  has  been 
given  for  a period  varying  from  half-an-hour  to  eight  hours.  The 
quantity  of  chloroform  consumed  has  been,  on  an  average,  about  one 
ounce  per  hour ; in  a few  cases  double  this  quantity  was  found  re- 
quisite. The  anaesthesia  has  been  in  almost  every  case  complete  ; 
that  is,  the  patient  on  awakening  has  declared  that,  while  under  the 
influence  of  the  chloroform,  she  was  utterly  unconscious  of  all  pain. 
In  most  cases  the  patient  has  lain  quiet  even  during  the  pains,  the 
presence  of  which  is  then  generally  indicated  by  the  breathing  be- 
coming more  rapid  and  somewhat  laboured.  In  other  cases,  there 
is  suppressed  moaning  during  the  pains,  or  even,  in  some,  loud 
manifestations  of  powerful  straining  and  muscular  exertion.  I cau 
state  most  positively  that  I have  seen  no  serious  symptom  which 
could  be  traced  to  the  chloroform,  in  any  one  case,  either  as  affect- 
ing the  mother  or  the  child.  Most  of  the  mothers  have  made 


OPINIONS  OF  PRACTITIONERS. 


217 


uncommonly  good  recoveries.  Those  who  have  had  children  pre- 
viously, have,  almost  without  exception,  stated  to  me  that  they  felt 
very  decidedly  stronger  after  delivery  than  on  former  occasions.  In 
two  cases  the  recovery  was  rather  slow ; but  this  was  owing  to  the 
patients  having  been  in  a very  delicate  state  during  pregnancy — and, 
in  both  instances,  I considered  the  chloroform  was  of  very  great 
service,  by  saving  their  strength.  All  the  mothers  are  now  in  their 
usual  health. 

“ In  no  one  of  the  twenty -four  cases  was  the  child  still-born. 
In  one  case,  labour  was  brought  on  at  the  end  of  the  seventh  month, 
owing  to  the  brim  of  the  pelvis  being  much  contracted.  The  child 
was  born  alive,  but  died  on  the  second  day.  All  the  other  children 
are  now  alive.  They  have  all  been  nursed  by  their  own  mothers, 
with  one  exception. 

I have  had  occasion  to  use  the  forceps  seven  times  since  the 
introduction  of  chloroform,  and  once  to  break  up  the  child’s  head 
and  extract  by  the  crotchet.  In  all  these  cases  the  patient  was  first 
put  into  a deep  anaesthetic  state,  and  in  most  she  lay  perfectly  still 
and  apathetic  during  the  operation.  All  the  mothers  have  done 
well,  except  in  the  case  of  craniotomy,  where  the  uterus  had  ruptured 
previous  to  the  use  of 'chloroform. — Yours,  etc. 

“G.  S.  Keith.” 


From  Dr.  Moir,  Edinburgh. 

“Since  the  beginning  of  December,  I have,  with  a very  few 
exceptions,  used  chloroform  in  the  course  of  my  midwifery  practice  ; 
and  I have  not  met  with  a single  case  where  any  unpleasant  effects, 
either  to  mother  or  child,  can  be  traced  to  its  use.  * 

“ As  far  as  my  observation  has  gone,  I think  it  will  be  found 
that,  in  some  cases,  the  chloroform,  if  freely  administered  at  an  early 
period  of  the  first  stage,  retards  the  pains  a little,  and  in  others  also 
lessens  their  power ; and  when  this  does  occur,  the  best  remedy  is 
either  to  intermit  its  use  till  the  labour  is  further  advanced,  or  to 
give  it  in  smaller  quantities  and  at  longer  intervals,  so  as  not,  at 
that  stage,  to  induce  complete  unconsciousness.  But,  whether  cor- 
rect or  not  in  this  opinion,  I am  quite  satisfied  that  the  second  stage 
is  much  accelerated,  especially  towards  its  termination,  by  the  chloro- 
form doing  away  with  the  resistance  offered  to  the  expulsion  of  the 
head  by  the  muscles  at  the  outlet  of  the  pelvis — and  this  to  such  an 
extent  that,  in  some  first  cases,  there  is  a risk;  unless  very  great  care 
is  taken,  that  the  perineum  be  slightly  lacerated,  from  the  head 


218 


APPLICATIONS  IN  MIDWIFEEY. 


being  so  rapidly  expelled  as  not  to  give  time  to  the  parts  to  yield 
so  rapidly  as  they  would  otherwise  do.  But  this  is  comparatively 
a very  rare  occurrence,  and  requires  to  be  mentioned  principally 
with  the  view  of  putting  young  practitioners  on  their  guard  against 
it,  and  of  leading  them  to  use  the  necessary  means  to  prevent  it. 

“ In  exhibiting  so  powerful  an  agent  as  chloroform,  I think  it  a 
point  of  importance  to  use  as  small  a quantity  as  is  compatible  with 
the  obtaining  of  its  full  anaesthetic  effects ; and  as  this  seems  to 
depend  much  upon  the  rapidity  with  which  it  is  conveyed  into  the 
system,  it  seems  a point  worthy  of  consideration  to  ascertain  the 
readiest  means  of  so  doing.  Various  instruments  have  been  invented 
for  this  purpose,  though  they  liave  been  almost  universally  super- 
seded by  the  use  of  the  handkerchief,  as  recommended  by  you,  and 
used  either  in  the  form  of  a hollow  cone,  applied  again  and  again, 
after  renewing  the  chloroform,  over  the  nose  and  mouth  of  the 
patient ; or  simply  folded  up  several  times,  and  frequently  having 
interposed  between  the  folds  a piece  of  wool  or  flannel,  with  the 
view  of  better  retaining  the  chloroform.  In  both  methods  there  is 
a considerable  loss  of  chloroform,  much  of  it  being  retained  in  the 
folds  of  the  handkerchief,  and  much  of  it  escaping  without  passing 
into  the  lungs,  or  else  passing  into  them  so  slowly  as  not  to  produce 
the  desired  effect.  I have,  for  some  time,  been  in  the  habit  of  using 
a linen  or  white  cotton  handkerchief,  folded  only  once,  or,  if  very 
thin,  folded  twice ; the  point  requiring  attention  being,  that  it 
should  not  be  so  thick  as  to  offer  any  impediment  whatever  to  free 
respiration  when  applied  over  the  mouth  and  nostrils.  Since  using 
the  chloroform  in  this  way  I have  never  failed  in  rapidly  producing 
the  ansestliesia,  either  in  my  own  practice,  or  when  accompanying 
some  of  my  patients,  who  were  several  months  advanced  in  preg- 
nancy, to  their  dentists  to  have  one  or  more  teeth  extracted.  For 
administering  the  vapour  to  patients  who  are  in  the  erect  position, 
the  chloroform  should  be  poured  on  that  part  of  the  handkerchief 
placed  on  the  palm  of  the  operator ; the  edge  of  the  little  finger 
should  then  be  applied  close  to  the  chin,  and  the  hand  gradually 
raised  up  towards  the  mouth,  till  the  sensation  of  choking  Avhich 
generally  accompanies  the  first  inspirations  has  passed  off,  after 
which,  the  handerchief  should  be  left  on  the  face,  and  the  hand 
removed ; the  patient  then  breathes  freely  through  that  part  of  the 
handkerchief  wetted  with  the  chloroform,  and  in  general  half-a- 
drachm  is  sufficient  to  produce  anaesthesia. 

In  obstetric  practice,  I find  it  the  most  convenient  plan  to  place 


OPINIONS  OF  PRACTITIONERS. 


219 


one  end  of  the  folded  handkerchief  under  the  left  cheek  of  the 
patient,  to  pour  a little  chloroform  on  it,  and  then,  taking  hold  of 
the  loose  end  of  the  handkerchief,  to  bring  it  gradually  near  the 
mouth,  till  it  can  be  left  there  without  inconvenience,  the  patient 
breathing  freely  through  it.  And  it  is  not  necessary  again  to  re- 
move the  handkerchief,  but  simply  to  pour  on  it  occasionally  a very 
few  drops,  w^henever  the  patient  begins  to  show  symptoms  of  return- 
ing consciousness,  or  on  the  accession  of  a pain.  The  only  precau- 
tions necessary  are,  to  raise  a small  fold  of  the  handkerchief  from 
the  skin  when  the  chloroform  is  to  be  applied,  so  as  not  to  blister 
the  skin  ; and  to  drop  the  chloroform,  not  on  that  part  of  the  hand- 
kerchief immediately  over  the  mouth,  but  a little  above  it,  so  that 
the  vapour,  being  heavy,  may  flow  down  tow'ards  the  mouth  or 
nostrils,  and  thus  be,  during  inspiration,  more  readily  received  into 
the  lungs.  By  adopting  this  plan,  I have  had  the  handkerchief 
applied  for  nearly  two  hours  without  removing  it  ; and  the  quantity 
of  chloroform  I have  used  in  single  patients  has  been  much  less 
than  other  practitioners  have  used  in  cases  of  the  same  duration. — 
Yours,  etc.  John  Moir.” 


From  Dr.  Malcolm,  Edinburgh. 

‘‘  Since  November  last  I have  employed  chloroform  in  above 
thirty  cases  of  labour,  and  with  the  most  satisfactory  and  delightful 
results.  A majority  of  these  were  first  labours.  I have  kept  my 
patients  under  it  for  periods  varying  from  half-an-hour  to  six  hours, 
and  have  never  found  the  slightest  unpleasant  effects  result  from  its 
use.  All  the  children  have  been  born  alive,  and  are  at  this  moment 
in  perfect  health,  with  the  exception  of  one  that  died  when  about  a 
month  old,  of  a sudden  and  severe  attack  of  dysentery.  All  the 
mothers  have  made  recoveries  with  rapidity  and  completeness,  far 
above  the  average  which  I had  previously  observed  in  my  practice. 
This  has  struck  me  as  the  more  remarkable,  seeing  a large  propor- 
tion of  my  patients  were  primiparous ; and  I can  only  attribute 
this  result  to  the  entire  absence  of  suffering  and  shock  to  the  ner- 
vous system  which  is  effected  by  the  use  of  chloroform.  Although 
in  a few  cases  my  patients  and  their  friends  have  at  first  objected  to 
the  use  of  anaesthesia  to  abolish  pains  which  they  considered  “ natu- 
ral,” yet  every  one  has  afterwards  expressed  to  me  sincere  gratitude 
for  saving  them  from  their  agonies  ; and  I am  sure  not  one  who  has 
experienced  the  beneficial  effects  of  the  practice  will  ever  submit  to 
these  agonies  again,  now  that  they  know  that  they  are  so  totally 


220 


APPLICATIONS  IN  MIDWIFERY. 


unnecessary,  and  can  be  so  easily  and  safely  abolished.  I have  re- 
peatedly found  the  mothers  of  my  patients  object  to  anaesthesia,  as 
if  they  grudged  that  their  daughters  should  not  experience  the  same 
sufferings  as  themselves — but  I have  uniformly  found  them  after- 
wards as  grateful  as  their  daughters  for  the  relief  administered. 

“ Generally,  I have  employed  about  an  ounce  of  chloroform  per 
hour.  I have  never  seen  the  uterine  contractions  arrested  by  its 
use,  although  I have  no  doubt  a large  dose  would,  when  necessary, 
have  that  effect.  I have  seen  no  case  of  hemorrhage,  or  convulsions, 
or  any  other  complication  whatever.  Let  me  add,  that  I cannot 
conceive  on  what  principle  the  employment  of  chloroform  in  natural 
labour  should  be  objected  to,  as  long  as  it  is  our  duty,  and  assuredly 
it  is  our  duty,  as  physicians,  to  relieve  and  mitigate  human  suffer- 
ing.— Yours,  etc.  E.  B.  Malcolm.” 

From  Dr.  Thomson,  Edinburgh. 

After  stating  the  details  of  ten  cases.  Dr.  T.  remarks : — 

“ Among  the  middling  classes  I have  met  with  more  difficulty  in 
using  the  chloroform  than  I had  anticipated,  as  it  has  only  been 
when  the  sufferings  of  the  patient  were  very  severe,  or  her  friends 
had  begun  to  dread  the  effects  of  prolonged  continuous  suffering  on 
her  constitution,  that  I could  get  my  wishes  carried  into  effect. 
That  fatal  Newcastle  case,  which  was  trumpeted  a good  deal  in  the 
newspapers,  is  still  haunting  their  minds,  and  is  very  frequently 
urged  by  some  timid  friend  when  you  propose  the  chloroform  to 
relieve  the  sufferings  of  the  patient. 

“ My  experience  of  it  has  been,  in  all  obstetric  instances,  analo- 
gous to  your  own ; with  one  exception,  I have  had  no  difficulty  in 
getting  the  patient  under  its  influence ; a minute  or  two  was  in 
general  sufficient  to  lay  the  most  restless  or  ungovernable  patient 
quiet  on  her  pillow. 

“ Not  the  slightest  post  partum  hemorrhage  has  taken  place  in  my 
ten  cases,  though  in  the  two  forceps  cases,  where  it  was  given  deeply, 
the  uterus  remained  flabby  for  nearly  thirty  or  forty  minutes,  and 
threw  off  the  placenta  with  difficulty. 

“ Its  relaxing  effects  are,  I think,  undeniable.  In  one  case,  the 
soft  parts  had  resisted  for  a considerable  time  the  descent  of  the 
head  ; they  yielded  very  readily  within  an  hour  after  the  chloroform 
was  begun.  I have  not  had  another  instance  of  this  kind  latel}^ ; 
but,  were  I to  meet  with  one,  I feel  confident  it  would  yield 


OPINIONS  OF  PRACTITIONERS. 


221 


with  much  more  facility  under  the  chloroform  than  without  it. — 
Yours,  etc.  Alex.  Thomson.” 

From  Mr.  Carmichael,  Edinburgh. 

“ I have  given  the  chloroform  in  twenty-six  cases  of  midwifery, 
four  of  which  were  first  labours  ; the  others  varied  from  the  second 
to  the  eleventh  pregnancy.  The  quantity  given  varied  from  two 
drachms  to  four  oz.,  and  the  length  of  time  during  which  it  was 
exhibited  from  a few  minutes  to  four  hours.  The  preparation  I 
have  used  has  always  been  that  of  Messrs.  Duncan,  Flockhart,  and 
Co.,  and  I have  never  seen  the  slightest  bad  effects  from  it,  either 
in  midwifery  or  other  medical  cases,  or  in  any  cases  where  I have 
administered  it  for  amusement,  except  occasional  sickness  where  it 
was  exhibited  shortly  after  a meal. 

“ I have  met  with  no  case  of  flooding  whatever.  I have  heard 
it  alleged  that  it  drives  away  the  milk ; but  I have  not  found  it  so, 
as  my  patients  have  all  been  able  to  nurse,  with  the  exception  of 
one  lady,  who  has  not  been  able  to  suckle  her  child  for  the  last 
three  times. 

“ In  all  of  these  cases  it  was  administered  with  the  greatest 
ease  and  with  perfect  success,  and  in  no  case  with  any  bad 
results. 

“ The  recoveries  have  been  certainly  more  than  usually  speedy. 
Indeed  the  only  objection  I have  met  with  as  to  its  use,  has  been 
on  the  part  of  the  monthly  nurses,  who  seem  afraid  that  the  new 
practice  will  curtail  their  attendanbe  and  pay. 

“All  the  children  were  born  alive,  and  are  doing  well.  The 
only  case  in  which  the  child  proved  the  least  refractory  was  a foot- 
ling one. 

“ I have  also  found  it  most  useful  in  cases  of  dysmenorrhcea,  in 
spasmodic  colic,  and  tic  doloureux. 

“ I also  gave  it  in  a case,  which  you  saw  along  with  me,  of 
most  severe  neuralgia  of  the  uterus,  with  the  most  perfect  success. 

“ In  no  case  whatever  have  I seen  any  bad  results  of  any  kind 
arise  from  the  use  of  the  chloroform. — Yours,  etc. 

“W.  S.  Carmichael.” 


From  Dr.  Burn,  Edinburgh. 

“ I regret  that  I cannot  give  you  the  number  of  cases  of  labour 
in  which  I have  exhibited  the  chloroform,  but  I may  state  that  I 


222 


APPLICATIONS  IN  MIDWIFEKY. 


have  given  it  repeatedly,  and  have  not  seen  any  bad  consequences 
either  to  the  mother  or  child  result  from  its  use. 

“ All  the  mothers  made  rapid  recoveries,  and  the  children  did 
not  appear  to  suffer  from  its  use. 

“ I have  given  the  chloroform  in  three  or  four  cases  of  adherent 
placenta,  where  the  uterus  Avas  firmly  contracted,  and  had  far  less 
difficulty  in  extracting  it  than  I have  experienced  in  similar  cases 
Avhere  the  chloroform  was  not  exhibited. — Yours,  etc. 

“ J.  Burn.” 


Brom  Dr.  Purdie,  Edinburgh. 

“ I have  now  used  chloroform  in  seventeen  cases,  which  I have 
noted,  and  in  every  instance  with  decided  effect,  not  merely  by 
lessening  suffering,  but,  I am  perfectly  conAunced,  by  the  most  care- 
ful observation,  by  shortening  the  duration  of  labour.  The  pains 
haA^e  never  in  my  experience  been  interfered  Avith,  except  by 
rendering  them  quicker,  and  far  more  effectual. 

“ There  is  one  of  the  cases  Avhich  I would  Avish  to  recall  to  youi 
memory.  The  patient,  thirty-eight  years  of  age,  Avas  in  her  first 
labour,  AAdiich  commenced  early  on  Wednesday  morning,  and  Avent 
on  Avell  but  slowly  till  the  evening,  Avhen  its  progress  ceased, 
although  the  pains  continued  regular  and  strong.  The  os  uteri  was 
well  dilated,  but  the  head  made  no  progress,  although  there  Avas  no 
very  evident  cause.  About  one  o’clock  on  Thursday  morning  I sent 
for  you  to  deliver  her  Avith  forceps.  On  your  arrival,  you  thought 
that  still  there  was  hope  of  the  labour  being  terminated  naturally. 
The  patient,  Avho  Avas  suffering  much,  Avas  then  put  under  the  influ- 
ence of  chloroform  and  ergot,  Avhile  you  Avaited  patiently  for  any 
advancement,  for  nearly  two  hours,  Avithout  effect.  You  then 
delivered  Avith  the  long  forceps,  Avhich  cost  you  great  exertion,  from 
the  head  being  impacted  in  the  brim.  The  patient’s  position  AA^as 
changed,  the  placenta  Avas  extracted,  she  Avas  bound  up  and  laid  in 
a comfortable  and  easy  posture,  in  Avhich  state  she  continued  to  sleep 
soundly  until  she  Avas  aAvakened  after  the  child  Avas  dressed,  the 
crying  of  Avhich  surprised  her,  as  she  had  not  been  conscious  of 
Avhat  had  taken  place  from  the  time  she  got  the  first  dose  of  the 
chloroform  after  your  arrival.  This  patient  had  an  excellent 
recovery.  I never  saAv  a patient  suffer  less  after  labour,  or  recoA'er 
more  rapidly.  I may  just  add,  that  there  are  few  things  vex  me 
more  Avith  regard  to  patients,  than  to  Avitness  the  sufierings  of  a 
childbed  patient,  who  Avill  not  allow,  from  ignorance  or  prejudice, 


OriNIONS  OF  PllACTITIONERS. 


223 


the  use  of  chloroform.  Happily,  however,  such  cases  are  very  rare 
among  us. — Yours,  etc.  W.  Purdie.” 

From  Dr.  Finlay,  Newhaven,  near  Edinburgh. 

“ I have  used  chloroform  in  a considerable  number  of  cases  of 
natural  labour.  It  was  with  much  reluctance  that  I first  admi- 
nistered it,  and  only  at  the  urgent  entreaty  of  a patient  who  was 
enduring  intense  agony  before  the  birth  of  a first  child.  It  was 
completely  successful.  Her  screams  had  been  audible  across  the 
street.  In  a few  minutes  they  ceased,  and  she  fell  asleep,  while  the 
uterus  continued  to  act  as  powerfully  as  before.  She  was  not  aware 
that  she  had  got  her  baby  until  a quarter  of  an  hour  after  it  was 
born.  In  five  of  the  other  cases  the  influence  of  the  chloroform 
was  as  complete.  In  the  other  three  cases  entire  insensibility  was 
not  induced,  but  the  sufferings  were  greatly  mitigated,  and  the 
relief  was  so  evident  to  the  patients,  that,  whenever  the  labour  pain 
was  approaching,  they  grasped  with  great  eagerness  the  handker- 
chief on  which  the  drug  was  sprinkled.  Satisfactory  as  these  cases 
have  been,  I have  hitherto  used  the  chloroform  with  considerable 
hesitation  and  caution,  and  only  when  it  was  asked  for  by  the 
patient.  But  every  trial  has  emboldened  me  to  employ  it  with 
greater  confidence  on  future  occasions.  In  each  of  my  cases  the 
placenta  was  soon  and  easily  detached ; in  none  of  them  did 
hemorrhage  occur ; and  they  all  made  excellent  recoveries. — ■ 
Yours,  etc.  A.  Finlay.” 


• From  Dr.  Gumming,  Edinburgh. 

“ I have  now  attended  thirty-five  cases  of  labour  under  chloro- 
form, and  it  has  been  used  in  all  with  marked  advantage.  All  the 
patients  have  made  unusually  good  recoveries ; and  I have  been 
very  much  impressed  by  the  fact,  which  was  remarked  by  the  first 
patient  submitted  by  me  to  chloroform,  and  repeated  by  all,  that 
the  convalescence  was  not  accompanied  by  the  crushed  and  dislocated 
feeling  that  they  have  experienced  without  it. 

“ I always  begin  by  introducing  the  chloroform  slowly  and 
gradually  into  the  lungs,  allowing  a large  proportion  of  air  to  be 
inhaled  along  with  it.  In  every  instance  it  was  administered,  not 
with  reference  to  the  quantity  given,  but  to  the  effect  produced — 
this  effect  being  complete  unconsciousness  during  the  pain ; and 
thus  administered,  I have  never  seen  any  unpleasant  or  absurd  con- 
sequences, nor  anything  to  excite  alarm  or  even  uneasiness. 


224 


APPLICATIONS  IN  MIDWIFERY. 


“ Two  of  the  cases  liad  had  large  floodings  in  a previous  labour ; 
with  the  chloroform  there  was  none.  This,  of  course,  I do  not 
impute  to  the  medicine ; but  it  at  least  tends  to  prove  that  hemor- 
rhage is  neither  a necessary  nor  a likely  consequence,  as  many  at  first 
were  disposed  to  imagine. 

“All  the  children  were  born  alive,  and  are  so  still.  None  of 
them  as  yet  give  the  slightest  indications  of  idiocy,  either  present  or 
future ; nor  have  I observed  in  any  the  temporary  stupefaction 
immediately  after  birth,  ascribed  to  the  presence  of  chloroform  in 
the  apartment,  that  some  have  remarked. 

“ I am  quite  satisfied  that,  if  properly  given,  it  acts  as  a calma- 
tive ; and  I believe,  from  what  has  passed  under  my  observation, 
that  very  many  of  what  are  called  exceptional  cases  are  not  so  in 
reality,  but  appear  to  be  such  from  error  in  the  mode  of  administra- 
tion, and  that  further  experience  will  amply  demonstrate  the  truth 
of  this. 

“ In  short,  I am,  unfortunately  for  the  appearance  of  veracity, 
compelled  to  say,  that  all  my  cases  hitherto  have  been  so  successful, 
the  recoveries  so  uniformly  good,  and  the  satisfaction  on  the  part  of 
the  patient  (I  may  add  also  my  own)  so  great,  that  I am  rapidly 
approaching  to,  if  indeed  I have  not  already  arrived  at,  the  convic- 
tion, that,  if  there  be  amj  sin  connected  with  chloroform.,  it  is  chargeable 
on  those  who  refuse  to  administer  it. 

“ I may  add,  that  not  one  of  those  patients  who  have  already 
inhaled  it  will  ever  be  denied  it  in  any  subsequent  pregnancy,  as 
they  have  repeatedly  assured  me ; and  certainly  I shall  not  attempt 
to  keep  it  from  them,  and  that  not  more  for  their  sake  than  my 
own. — Yours,  etc.  W.  CUMMING.” 

If  necessary,  I might  have  adduced  more  evidence  in  favour 
of  the  anaesthetic  effects  of  chloroform  in  midwifery  practice,  from 
Dr.  Beilby,  Dr.  Zeigler,  Dr.  Weir,  Dr.  Young,  Dr.  Menzies,  Dr, 
Gilchrist,  Dr.  Campbell,  and  other  medical  practitioners  in  Edin- 
burgh, who  have  been  using  it. 

In  order  to  vary  the  kind  of  evidence,  I shall  next  adduce  ex- 
tracts from  various  communications  which  I have  received  on  the 
use  of  chloroform  in  midwifery,  front  medical  correspondents  in 
different  parts  of  Scotland,  England,  and  Ireland.  It  is  needless,  I 
believe,  to  attempt  to  arrange  them  in  any  special  order;  and  I shall 
content  myself,  therefore,  with  beginning  with  the  letters  of  those 
practitioners  who  live  farthest  north,  and  proceed  southward. 


OPINIONS  OF  PRACTITIONEKS. 


225 


The  following  is  an  extract  from  a letter  written  to  me  this 
summer : — 


From  Dr.  Grigor  of  Nairn. 

“ Dr.  Allan  of  Forres  and  myself  would  as  soon  think  of  going 
to  an  obstetric  case  without  our  chloroform  phial,  as  we  would  of 
going  to  bleed  a patient  without  a lancet.  In  this  quarter,  doctors 
are  only  called  in  when  things  are  going  wrong,  or  in  extreme 
cases ; so  that,  since  your  grand  discovery,  he  and  I have  only  used 
it  in  about  twenty-four  cases,  in  all  which  it  came  up  to  all  you 
have  written  about  it — no  still-born  children,  mothers  recovering 
well,  fewer  after-pains,  etc.  etc.  One  of  my  cases  was  a first  child, 
the  mother  nearly  forty-eight  years  of  age,  weakly  in  constitution, 
and  of  small  formation.  Had  it  not  been  for  the  chloroform;  I do 
think  she  would  have  sunk. — Yours,  etc.  J.  Grigor.” 

Dr.  Dyce,  lecturer  on  midwifery  in  Marischal  College,  Aber- 
deen, favoured  me  some  time  ago  with  the  following  interesting 
communication  regarding  the  obstetric  employment  of  chloro- 
form : — 

“ I have  reports  from  my  friends  Drs.  Harvey,  Pirrie,  and 
Gilchrist,  ,all  of  whom,  I was  aware,  had  been  employing  it.  I 
may  at  once  state  that  I consider  it  a most  invaluable  agent ; that 
I have  every  confidence  in  its  safety ; that  I recommend  it  almost 
on  every  occasion ; that  no  evil  consequences  have  ever  attended  its 
use ; and  that  I have  found  its  effects  nearly  alike  in  all.  I have 
used  it  eleven  times.  The  labours  have,  with  one  exception,  been 
natural.  The  exception  was  a breech  case,  and  a first  child.  Two 
of  the  eleven  children  were  lost ; one  -was  putrid,  and  in  the  other 
(the  breech  case),  though  the  funis  did  pulsate  for  some  minutes, 
the  child  could  not  be  recovered. 

“ Dr.  Harvey  has  given  me  a brief  account  of  four  cases  de- 
livered under  chloroform ; all  the  children  were  born  alive. 

“Dr.  Gilchrist  at  \Yoodside  writes  to  me — ‘ I have  observed  no 
evil  results  to  the  infants  themselves  from  the  use  of  chloroform.’ 
He  does  not  state  the  number  of  his  cases ; but  I presume  they 
have  been  numerous,  from  his  remarking,  that  ‘ latterly  I have  not 
used  this  agent  so  generally  as  when  it  was  novel,  reserving  it  now, 
unless  when  urgently  requested  by  the  patient,  for  cases  unusually 
painful,  whether  arising  from  excessive  sensibility  of  the  system, 
rigidity  of  the  soft  structures,  or  cases  requiring  manual  assistance.’ 


226 


APPLICATIONS  IN  MIDWIFEKY. 


“ Dr.  Pirrie  has  employed  chloroform  in  fourteen  cases.  Ten  of 
these  were  natural,  two  instrum,ental,  and  one  a case  of  turning.  He 
says,  ‘ As  to  the  children,  they  have  all  been  born  alive,  and  continue 
to  go  on  satisfactorily.’ 

“ I never  use  it  early  in  labour ; generally  the  second  stage  has 
come  on,  or  at  least  the  os  uteri  is  tolerably  well  dilated.  This 
appears  to  be  the  practice  of  my  brethren  here.  I then  keep  the 
patient  in  a state  of  insensibility,  more  or  less  complete,  during  the 
future  progress  of  the  labour.  Occasionally  I have  allowed  them 
to  come  completely  out  of  the  anaesthetic  state  ; but,  on  the  recur- 
rence of  the  pain,  the  patients  invariably  and  urgently  seek  for  the 
handkerchief.  When  I used  chloroform,  I imagined  that  the  in- 
tenseness of  the  stupor  induced  did  lessen  the  frequency  and  force 
of  the  pains,  and  even  put  a stop  to  the  labour  altogether ; and  I 
am  still  of  opinion,  that  if  the  full  effect  is  produced  and  kept  up 
for  any  time,  the  pains  will  cease  ; but  if  a more  moderate  effect  is 
produced,  so  that  consciousness  to  a certain  extent  remains,  my 
conviction  is,  that,  instead  of  checking  uterine  action,  its  use  enables 
the  organ  to  act  with  more  freedom ; the  mental  influences  are 
quickened ; and,  more  than  this,  it  has  a decided  power  in  relaxing 
the  soft  parts,  and  thus  removing  a very  frequent  cause  of  protracted 
labour.  I had  a very  interesting  case,  illustrative  of  these  remarks, 
in  January  last,  in  a lady  in  her  fifth  pregnancy,  of  a very  irritable, 
anxious,  and  highly  nervous  temperament,  who  had,  previously  to 
labour,  determined  to  use  this  wonderful  agent.  Her  former  labours 
had  always  been  tedious,  and  very  painful  throughout  every  stage. 
This  commenced,  and  had  continued  for  a couple  of  hours  before  I 
saw  her.  She  was  complaining  much  of  the  severity  of  the  pains, 
especially  of  her  inability  to  move  from  one  posture.  Her  anxiety 
and  agitation  were  very  considerable  ; her  pulse  was  above  100,  and 
her  body  'vvas  already  wet  with  perspiration.  On  examination  I 
found  the  parts  rigid,  and  the  os  not  larger  than  a shilling,  while 
the  rectum  actually  encroached  upon  the  vagina  from  its  loaded 
state.  I determined,  therefore,  on  emptying  the  gut  by  an  enema 
before  employing  the  chloroform,  and  mentioned  this  to  my  patient, 
and  gave  the  nurse  the  necessary  instructions.  I very  soon  found 
that  I had  added  not  a little  to  her  already  excited  state,  as  she 
was  not  prepared  for  delay,  and  would  only,  after  some  persuasion, 
consent  to  its  exhibition,  and  only  then  on  condition  that  imme- 
diately after  she  was  to  be  allowed  the  ‘ stuff.’  Her  request  was 
complied  with,  and  I confess  to  you  its  effect  on  her  general  state. 


OPINIONS  OF  PIIACTITIONEPS. 


227 


from  the  moment  she  was  under  its  influence,  not  only  gratified 
myself,  but  pleased  her  friends,  who  complained  much  of  her  im- 
patience and  her  imagined  evils.  A few  inhalations  sufficed  to 
induce  insensibility,  before  which  she  gave  one  or  two  hysterical 
laughs,  and  made  some  incoherent  remark.  She  then  became  still 
and  quiet,  until  a pain  returned — the  only  indication  of  which  was 
a gentle  writhing  of  the  body.  Her  pulse  very  soon  fell  to  80,  at 
which  it  remained  ; her  skin  became  cool ; the  parts  rapidly  re- 
laxed ; she  moved,  and  allowed  herself  to  be  moved  in  any  direc- 
tion readily;  the  pains  were  certainly  more  regular  and  efficient 
than  in  any  of  her  former  labours ; and  in  two  hours  and  a half 
from  the  first  inhalation,  the  child  was  born.  Once  only  during 
this  period,  and  that  was  after  one  hour  had  elapsed,  was  she  per- 
fectly sensible.  This  was  permitted  at  the  solicitation  of  the  nurse 
and  friends,  who  had  not  seen  chloroform  used  before,  and  could 
not  be  convinced  that  so  sudden  a change  could  exist  and  the  labour 
progress  perfectly.  They  soon  had  evidence  of  this,  by  the  patient 
screaming  out  in  her  former  impatient  tone,  ‘ Pain,  pain  ! where  is 
the  handkerchief  P From  this  time  until  delivery  she  was  per- 
fectly unconscious.  The  placenta  came  away  naturally  in  ten 
minutes.  The  roller  was  put  on,  some  of  the  soiled  things  were 
changed,  and  it  was  not  for  several  minutes  ere  she  was  convinced 
that  her  trials  were  over.  I need  hardly  say  that  she  was  gratified 
in  the  highest  degree  to  find  that  she  had  escaped  so  much  of  her 
former  sufferings,  and  expressed  her  deep  thankfulness  for  so  valu- 
able a boon.  The  child  was  putrid.  Her  recovery  was  perfect,  and 
more  rapid  than  on  any  former  occasion. 

“ In  my  practice  I have  met  with  no  instance  of  chloroform 
failing  in  producing  its  usual  effects  in  a very  few  minutes,  where 
it  was  willingly  and  readily  inhaled  ; in  some  nervous  patients,  a 
few  seconds  are  sufficient  for  this  purpose.  In  the  case  I have  just 
given,  I was  surprised  at  the  few  inhalations  she  took  ; and  Dr. 
Pirrie  mentions  that  one  of  his  patients  was  so  highly  susceptible  of 
its  effects,  that,  on  making  three  or  four  inhalations,  the  state  of 
ana3sthesia  became  so  complete  that  the  labour  was  entirely  sus- 
pended ; he  therefore,  in  this  case,  discontinued  its  use.  On  some 
occasions  I had  difficulty  in  persuading  the  patients  to  use  it ; hence 
a longer  time  elapsed.  In  one  case,  when  persuasion  failed,  I 
watched  an  interval  of  drowsiness,  and,  in  spite  of  herself,  brought 
the  woman  fairly  under  its  influence,  in  which  state  she  remained 
for  twenty  minutes,  when  the  child  was  born  unconsciously.  Its 


228 


APPLICATIONS  IN  MIDWIFERY. 


cry  aroused  her,  she  turned  herself  hastily  around  with  an  inquiring 
look,  and  after  a momentary  gaze  said,  ‘ What  is  that  ? you  have 
been  giving  me  the  stuff.’ 

“ The  quantity  of  liquid  used  has  varied  in  my  hands  from 
Iss  to  ^iiss.  This  last  quantity  was  expended  in  the  case  of  a 
young  woman,  of  eighteen  years  of  age,  pregnant  of  her  first  child, 
and  who  was  more  or  less  under  the  influence  of  chloroform  for  five 
hours.  As  this  was  amongst  my  first  cases,  if  not  the  very  first, 
and  the  longest  period  in  which  I have  employed  this  agent,  per- 
haps you  will  excuse  my  giving  it  somewhat  in  detail,  more  espe- 
cially as  ergot  was  given  along  with  it,  which  I am  not  aware  that 

I had  seen  anywhere  recommended.  Jane , set.  eighteen, 

unmarried;  first  child,  December  18,  1847.  When  seen  at  five 
P.M.,  the  membranes  were  reported  to  have  ruptured  twelve  or 
thirteen  hours  before  ; on  examination,  the  os  uteri  was  found 
dilated  to  the  size  of  half-a-crown,  and  the  breech  was  discovered 
as  the  presenting  part ; the  pains  were  frequent,  irregular,  at  times 
only  effectual,  but  they  had  been  increasingly  severe  during  the 
after  part  of  the  day,  and  now  were  strong. 

“ About  seven  P.M.,  after  some  persuasion,  she  first  inhaled  the 
chloroform.  She  soon  became  insensible  ; it  was  then  only  pre- 
sented to  her  at  intervals  as  a pain  recurred,  a single  inhalation 
being  generally  sufficient.  She  laughed  and  sang  for  a few  minutes, 
but  at  length  seemed  perfectly  unconscious,  and  we  were  only  sen- 
sible that  she  had  pain  by  her  now  and  then  rolling  about,  as  is  the 
case  when  labour-pains  continue  under  convulsions.  For  an  hour 
she  was  kept  in  this  state  ; but  thinking  the  pains  were  becoming 
more  distant,  and  the  progress  of  the  labour  slower,  she  was  allowed 
to  come  out  of  this  torpid  state.  Soon  after  3SS.  of  powdered  ergot 
was  given,  and  repeated  four  times,  at  intervals  of  a quarter  of  an 
hour.  The  pains  now  became  stronger  and  more  frequent,  and  my 
patient,  who  was  conscious  of  the  powerful  agency  of  the  chloroform, 
and  the  advantages  she  had  derived,  insisted  on  its  repetition.  She 
had,  in  fact,  secreted  the  handkerchief,  and  was  now  keeping  it  at 
her  mouth.  But,  alas ! its  talismanic  powers  had  vanished  ; she 
threw  it  rather  angrily  at  the  student,  who  at  that  moment  sat  by 
her  bedside,  desiring  him  to  give  her  the  bottle  in  its  stead  ; slie 
assured  us  that  she  had  felt  no  pain  until  now,  that  she  had  been 
dreaming  of  her  illness,  which  she  believed  was  finished.  From 
this  time  (nine  o’clock),  until  her  delivery,  which  took  place  between  ^ 
one  and  two  o’clock  the  following  morning,  she  was  kept  in  a per- 


OPINIONS  OF  PRACTITIONEPS. 


229 


fectly  unconscious  state,  at  times  more  so  than  at  others,  according 
to  the  severity  of  the  pains.  Towards  the  end  of  the  labour,  the 
throes  were  very  severe,  but  during  none  of  them  did  the  patient 
complain  of  the  slightest  pain.  The  only  indication,  as  I have 
already  said,  of  apparent  suffering,  was  a movement  of  the  body, 
and  occasionally  a low  moan.  The  child  in  this  case  did  not  breathe 
or  cry ; it  was  not,  therefore,  legally  in  life,  though  the  funis  pul- 
sated for  some  minutes. 

“ I can  scarcely  think  that  the  death  ought  to  be  attributed  to 
the  chloroform,  or  even  to  the  ergot.  The  length  of  the  labour, 
the  nature  of  the  presentation,  and  especially  its  being  a first  child, 
were  almost  against  its  being  born  alive.  So  that,  with  this  excep- 
tion, no  injury  has  befallen  the  infant  in  the  practice  of  any  of  us 
here  who  have  employed  chloroform. 

“ I have  only  further  to  say,  that  the  recoveries  in  every  case  have 
been  most  satisfactory.  They  appeared  even  more  rapid  than  under 
ordinary  circumstances. — Yours,  etc.  R.  Dyce.” 

From  Mv.  Lawrence,  Montrose. 

“ I am  sorry  I cannot  furnish  much  information  as  to  the  em- 
ployment of  chloroform  in  midwifery  in  this  quarter.  It  has  been 
very  little  used  by  myself  or  brethren,  owing  chiefly  to  a very 
general  prejudice  on  the  part  of  our  parturient  patients  against  it. 
The  very  last  case  I attended,  the  patient  resolutely  refused  it, 
although  suffering  very  severe  pain ! However,  in  one  of  those  in 
which  I administered  it,  and  to  which  I had  gone  unprovided  with 
the  chloroform,  my  patient  compelled  me  to  send  for  it ! In  one 
case,  in  which  a patient  of  mine  had  convulsions  in  her  first  labour, 
I exhibited  chloroform  at  her  second  confinement  with  the  usual 
success. 

“I  have  seen  no  injurious  consequences  of  any  kind. — • 
Yours,  etc.  Samuel  Lawrence.” 

From  Dr.  Steele,  Montrose. 

“ I have  used  chloroform  in  midwifery  practice  on  six  separate 
occasions.  In  two  of  the  cases,  it  was  given  to  the  extent  of  j^ro- 
ducing  only  a partial  immunity  from  suffering ; but  with  the  effect 
of  converting,  especially  in  one  to  whom  it  was  administered  for 
four  hours,  what  would  have  been  a very  severe  into  a very  easy 
labour.  In  the  other  four,  the  effect  was  highly  satisfactory ; two 


230 


APPLICATIONS  IN  MIDWIFERY. 


of  the  children  being  bom  without  the  consciousness  on  the  part 
of  the  mothers,  for  some  time  after,  of  that  event  having  taken 
place.  One  lady  remarked,  that  she  thought  ‘ the  march  of  intellect  ’ 
had  never  taken  a happier  direction  than  when  it  led  to  the  dis- 
covery of  chloroform. 

“ All  the  children  did  well.  One  of  them,  however,  was 
asphyxiated  for  nearly  a quarter  of  an  hour  after  its  birth. 

“ From  the  little  experience  T have  had  of  chloroform,  any 
opinion  of  mine  as  to  its  merits  is  not  entitled  to  much  weight.  It 
seemed  certkinly,  in  several  of  my  cases,  to  prolong  the  interval 
between  the  pains,  and  thereby  retard  the  termination  of  the 
labour ; and  I thought  also  that  the  uterine  action  was  sometimes 
less  effective  when  the  patient  was  under  the  power  of  the  medicine. 
— Yours,  etc.  George  Steele.” 

From  Dr.  Paton,  Dundee. 

“ I have  ascertained  that  chloroform  has  been  employed  in  up- 
wards of  fifty  cases  up  to  this  date  (5th  June  1848),  several  of  them 
instrumental,  and  with  the  best  effect ; and  no  bad  consequence 
has  attended  it  either  to  the  mothers  or  children.  All  the  children 
have  been  born  alive.  In  the  cases  in  my  own  practice  in  which 
I have  used  it,  it  speedily  induced  the  anaesthetic  state,  and  appeared 
to  accelerate  the  uterine  action  in  some.  The  recoveries  of  the 
mothers  were  more  favourable  than  in  former  instances  where  no 
such  agent  was  employed.  In  all,  the  children  were  born  alive, 
except  one,  where  the  child  was  acephalous. 

“ To  explain  the  small  number  of  cases  in  which  it  has  been 
used  here,  I ought  to  mention  that,  in  consequence  of  the  deaths  of 
two  ladies  in  a respectable  rank  pf  life,  from  puerperal  fever,  when 
it  was  epidemic  a few  months  ago — in  both  of  which  cases  chloro- 
form was  used — the  public,  of  course,  attributed  the  unfortunate 
result  to  the  new  agent ; and  since  then  it  has  been  difficult,  and  in 
many  instances  impossible,  to  overcome  the  prejudice  against  it. 
Of  late,  however,  from  the  favourable  opinion  entertained  of  it  by 
those  who  have  had  it  administered,  it  is  not  so  frequently  objected 
to — Yours,  etc.  Geo.  Paton.” 

Dr.  Anderson,  president  of  the  Medico-Chirurgical  Society  of 
Glasgow,  and  one  of  the  most  experienced  and  esteemed  physicians 
in  that  city,  some  time  ago  wrote  me  a letter,  from  which  I make 
the  following  extract : — 


OPINIONS  OF  PRACTITIONERS. 


231 


“ Not  being  connected  with  any  obstetric  institution,  and  having 
now  little  practice  of  this  kind  amongst  the  poor,  I am  sorry  I can- 
not offer  you  any  sufficient  statistics  on  the  use  of  chloroform ; but 
I have  had  so  much  reason  to  be  satisfied  with  its  effect,  that  I 
almost  always  use  it,  and  most  of  my  patients  have  expressed  them- 
selves as  strongly  in  its  favour  as  you  have  done.  I recollect  only 
two  exceptions,  where,  although  the  usual  effects  were  produced, 
both  patients  complained  that,  previous  to  the  full  anaesthetic  effects, 
their  feelings,  instead  of  being  agreeable,  were  very  much  the  reverse. 
One  lady  said  she  felt  it  like  approaching  insanity  ; and  that  she 
would  rather  endure  the  labour  pains  than  be  subjected  to  this 
again.  In  no  case  have  I had  reason  to  suppose  that  mother  or 
child  suffered  injury.  All  the  mothers  have  done  well,  and  several  of 
them  have  spontaneously  remarked  that  they  made  better  and  quicker 
recoveries  than  after  former  accouchements.  In  this  I coincide. 
Two  children  were  still-born.  One,  in  the  sixth  month,  died  during 
parturition,  after  long-continued  discharge  of  the  liquor  amnii  for 
many  weeks  before  the  induction  of  labour ; the  other,  in  the  eighth 
month  after  hemorrhage  from  fatigue,  followed  by  protracted  labour ; 
in  this  case  a placental  clot  was  found  after  delivery,  so  that  the 
child’s  death  was  sufficiently  accounted  for. 

“ On  the  whole,  my  experience  of  chloroform  in  parturition  is 
more  favourable  than  in  other  cases,  where  I have  several  times 
seen  it  produce  alarming  spasmodic  and  other  nervous  symptoms, 
followed  by  sickness.  These  effects,  I think,  are  most  apt  to  occur 
in  subjects  who  have  had  spinal  irritation,  or  an  excitable  state  of 
the  nervous  system,  or  who  use  the  chloroform  when  exhausted,  or 
after  abstinence  from  nourishing  food. — Yours,  etc. 

‘‘  A.  D.  Anderson.” 

The  following  communication  was  sent  me  in  June  last 

By  Mr.  Spencer,  Douglas,  Isle  of  Man. 

“ I forget  how  often  I had  used  the  chloroform  when  I last  wrote 
you  ; but,  since  then,  I have  used  it  frequently,  with  invariable 
success  so  far  as  it  is  concerned.  There  have  been  no  still-born 
children  from  its  use,  and  all  the  children  have  continued  to  thrive 
well ; none  as  yet  have  had  a fit  from  teething — this  I consider  a 
great  matter.  AVe  w^ant  some  powerful  proof  here  to  bring  it  into 
general  use.  I cannot  use  it  in  half  my  cases,  as  I would  not  do  it 
without  leave  from  the  patient.  I had  a case  of  puerperal  mania  the 


232 


APPLICATIONS  IN  MIDWIFERY. 


other  day,  and  did  not  use  it  in  it.  If  I had  used  it,  I should  have 
been  blamed.  This  is  so  small  a place  that  everything  one  does  is 
at  once  known.  I have  often  operated  under  its  use,  with  no  ill 
effect. — Yours,  etc.  J.  H.  F.  Spencer.” 

From  Mr.  Ceely,  Aylesbury. 

“ I have  much  pleasure  in  communicating  to  you  the  general 
results  of  my  very  limited  use  of  anaesthetic  agents  in  midwifery.  I 
have  used  both  ether  and  chloroform  in  numerous  operations,  small 
and  great,  in  public  and  private  practice,  have  been  several  times 
the  subject  of  their  influence,  and  have  repeatedly  employed  them 
in  hysteria,  epilepsy,  and  other  nervous  and  spasmodic  affections ; 
but  my  employment  of  them  in  midwifery  has  been  more  limited, 
and  at  present  restricted  chiefly  to  primiparous  and  difficult  or 
tedious  cases.  I have  used  them  in  only  six  cases  as  yet. 

“ It  has  happened  that  most  of  my  late  obstetric  cases  have  been 
so  easy  and  so  rapid  as  to  supersede  the  use  of  chloroform.  My 
own  observations  of  its  effects  in  midwifery  would  induce  me  to 
urge  its  use  in  all  severe,  protracted,  or  operative  midwifery ; and  in 
any  case  of  natural  labour,  with  only  the  ordinary  suffering,  I would 
not  hesitate  to  employ  it,  with  the  concurrence  of  the  patient  or 
friends,  if  I saw  no  contra-indication ; because  I believe  that,  in 
proper  doses,  with  suitable  management,  it  is  harmless,  and  may  be 
beneficial ; but  if  the  patient,  under  these  circumstances,  were 
averse,  I should  not,  of  course,  press  it.  Neither  do  I think  I should 
venture  to  employ  it  in  natural  and  easy  labour,  where  I suspected 
or  knew  that  subsequent  hemorrhage  would  arise,  from  flabbiness  of 
fibre  and  flaccidity  of  the  organ ; because  I think  the  secale  cornutum, 
during  the  last  hour  or  two  of  such  labours,  has  in  my  hands  been 
so  beneficial,  and  seems  more  appropriate. 

In  all  the  cases  in  which  I have  employed  ether  or  chloroform, 
the  patients  and  their  friends  have  been  perfectly  satisfied  and 
gratified  with  the  results,  and  abundantly  thankful  for  the  boon. 
In  only  one  case  has  there  been  any  sickness  or  syncope.  In  a town 
about  twelve  miles  hence,  it  has  also  been  successfully  used  by  ^Ir. 
Knight  of  Brill,  in  several  cases.  In  Bicester,  I have  heard  of  its 
use,  but  chiefly  by  younger  medical  men. 

“ I will  only  add  that,  in  using  the  chloroform,  I have,  in  some 
of  the  cases,  now  and  then  omitted  to  repeat  the  dose,  to  show  the 
friends  and  attendants  how  differently  the  patient  was  situated  ; but 


OPINIONS  OF  PRACTITIONERS. 


233 


the  latter  has  soon  removed  any  hesitation  of  the  friends  by  calling 
out  hastily  for  that  ‘ nice  chloroform  ’ again. — Yours,  etc. 

“ Robert  Ceely.” 

In  a printed  pamphlet^  obligingly  furnished  me  some  time  ago 
by  Mr.  Stallard,  surgeon  to  the  Leicester  General  Dispensary,  that 
gentleman  observes — 

“ I have  exhibited  the  chloroform  in  upwards  of  thirty  cases  of 
midwifery  during  the  present  year,  and  they  have  included  a greater 
number  of  severe  cases  than  the  general  experience  would  support ; 
this  is  accounted  for  by  the  fact  that  two  of  the  worst  were  pauper 
patients,  to  whom  the  surgeon’s  attendance  is  required  only  in  cases 
of  unusual  severity.  One  other  formidable  case  also  occurred  to  my 
father,  and  in  it  I was  requested  by  him  to  use  the  chloroform.  In 
this  experience  I have  never  once  observed  the  least  retardation  of 
the  parturient  paroxysms,  so  long  as  absolute  insensibility  icas  not  induced; 
and  in  several  cases  the  pains  were  palpably  increased.  When  a 
patient  is  suffering  acute  pain  she  does  all  in  her  power  to  suppress 
it,  and  the  act  of  doing  so  is  well  known  to  retard  the  process  of 
parturition ; when,  therefore,  the  pain  is  no  longer  felt,  the  effort 
to  suppress  it  no  longer  ensues,  and  the  accouchement  is  accelerated 
in  a remarkable  degree.  But  again,  it  has  been  argued  that  the 
pain  of  labour  is  desirable ; and  that  it  is  wrong  to  interfere  with 
this  natural  indication  of  what  is  going  on.  Now,  with  this 
assertion  I am  totally  at  variance ; there  is  nothing  so  depressing 
to  the  powers  of  life ; nothing  so  soon  exhausts  the  already  feeble 
body ; nothing  so  effectually  prevents  the  sufferer  from  aiding 
nature  by  her  volitional  effort,  as  pain  j and,  consequently,  nothing 
so  powerfully  maintains  the  strength,  or  invigorates  the  system, 
as  its  annihilation.  ...  In  the  thirty  cases  I have  attended  I 
have  not  had  a single  case  of  flooding,  and  two  individuals  had 
never  been  free  from  it  on  former  occasions.  This  is,  in  my  opinion, 
an  additional  recommendation  for  its  exhibition ; and  in  all  those 
excitable  persons  in  whom  flooding  is  most  likely  to  occur,  the 
diminution  of  fear  and  excitement  caused  by  its  exhibition  has  a 
direct  tendency  to  prevent  the  flooding.  Nothing  but  a very  ex- 
tended experience  can  justify  any  conclusion  upon  this  head ; as  far 
as  my  own  experience  goes,  I am  decidedly  of  opinion  that  chloro- 
form exerts  no  perceptible  influence  upon  the  child.” 

^ Fractical  Observations  on  the  Administration  and  Effects  of  Chloroform  in 
Natural  Labour^  p.  16,  etc. 


234 


APPLICATIONS  IN  MIDWIFERY. 


From  Dr.  Protheroe  Smith,  London. 

“ I have  records  in  my  own  practice  and  that  of  my  friends  of 
upwards  of  125  cases  of  anaesthetic  labour ; and,  with  one  exception, 
all  have  done  well.  In  several  thus  treated,  no  hemorrhage  has 
ensued,  though  in  previous  labours  there  was  flooding.  In  nearly 
all,  the  getting  up  has  been  more  speedy,  requiring  no  aid  of  opiates 
and  purgatives ; and  it  is  my  sincere  conviction  that  chloroform 
lessens  the  chance  of  puerperal  inflammation  and  fever.  I usually 
employ  my  inhaler  to  administer  it,  and  with  it  I fancy  I can  ad- 
minister it  with  greater  success  and  precision.  I have  kept  patients 
under  its  influence  from  halLan-hour  to  twenty-eight  and  a half 
hours.  I have  used  it  in  cases  in  which  bronchitis  was  present,  and 
one  lately,  in  which,  at  the  time,  there  was  complete  aphonia.  She 
has  never  had  so  good  a time — in  four  or  five  previous  births  she 
had  protracted  recoveries,  floodings,  peritoneal  attacks,  etc. ; these 
she  has  wholly  escaped.  I have  used  it  in  turning  and  forceps 
cases,  etc.,  and  in  all  I have  been  most  successful.  In  administering 
chloroform  I adopt  your  plan  of  inducing  rapidly  complete  sleep, 
ajid  afterwards  keep  up  the  effect  by  repeating  the  inhalations  at 
each  recurrence  of  uterine  effort.  The  other  day  I had  three  cases, 
the  one  after  the  other,  which  strikingly  illustrated  the  various 
effects  of  the  chloroform  on  different  subjects — 1st,  a primipara,  set. 
twenty  (administered  in  the  second  stage),  kept  under  its  influence 
four  and  a half  hours,  slept  sweetly,  without  any  movement  of  the 
body,  save  during  the  last  expulsive  efforts,  when  the  usual  ab- 
dominal muscles  were  called  into  action.  The  ‘ pains  ’ under  the 
chloroform  became  more  frequent  and  powerful,  and  a fine  male 
child  was  born.  After  the  expulsion  of  the  child  the  patient  awoke, 
refreshed  as  from  a sweet  sleep,  without  any  pain  or  evidence  (save 
the  advent  of  her  first-born)  of  having  been  confined,  as  far  as  her 
own  feelings  were  concerned.  The  uterus  contracted  firmly,  and  I 
instantly  left  her  for  the  second — a lady  of  title.  She  required  to 
inhale  for  a minute  and  a half  (in  the  third  stage)  before  the  in- 
duction of  anaesthesia  was  complete,  when  she  became  very  talkative, 
addressing  her  maid  in  French,  speaking  of  matters  wholly  foreign 
to  her  condition,  and  of  an  amusing  character,  as  though  she  was 
perfectly  at  ease  and  had  nothing  to  do  with  the  labour,  which  ad- 
vanced rapidly,  and  terminated  in  an  hour  from  the  first  exhibition 
of  chloroform.  On  recovery,  in  about  three  minutes  after,  she  was 
introduced  to  a fine  boy,  and  remarked  she  had  been  sound  asleep. 


OPINIONS  OF  PRACTITIONERS. 


235 


The  third  case  had  the  chloroform  in  the  second  stage  ; she  slept 
soundly  in  half-a-minute,  and  then  became  conscious  of  what  was 
going  on — described  to  the  nurse,  who  stood  by,  the  progress  of  the 
labour,  and  observed  that  she  was  greatly  delighted  that  she  had 
her  senses,  and  yet  was  wholly  unconscious  of  any  pain  or  distress 
of  any  kind.  She  remarked,  that  with  the  entire  freedom  from 
suffering,  she  was  sensible  of  the  progress  of  the  labour,  as  though 
it  was  effected  by  an  agency  with  which  she  was  altogether  uncon- 
nected. During  the  last  throe  I made  her  sleep ; so  she  was 
ignorant  of  the  birth  of  a fine  boy : in  this  and  the  second  case  the 
placenta  immediately  followed  ; the  abdomen  and  uterus  contracted 
firmly.  In  all  three  cases  no  after-treatment  was  required,  and  they 
make  rapid  recoveries. — Yours,  etc.  Protiieroe  Smith.” 


From  Dr.  Kigby,  London. 

“ Of  course  I use  the  chloroform  in  midwifery,  but  I cannot 
think  that  a large  dose  at  first  is  the  best  way.  In  almost  all 
private  patients,  you  can  draw  the  line  between  loss  of  pain  and  loss 
of  consciousness.  I give  but  a small  quantity  at  a time  ; the  patient 
takes  it  herself  (on  a strip  of  sponge),  and  when  it  is  exhausted  she 
asks  for  more. — Yours,  etc.  E.  Kigby.” 


From  Mr.  Lansdowne,  Bristol. 

“ I have  now  used  ether  or  chloroform  in  seventy-one  midwifery 
cases  ; I have  two  modes  of  administering  it,  the  one  with  a bladder 
in  which  is  placed  a brass  pipe  with  a stopcock,  and  into  this  is 
screwed,  after  I have  poured  the  chloroform  into  the  bladder,  a 
piece  of  elastic  tubing  with  a mouthpiece,  the  whole  being  pierced 
with  a bore  f of  an  inch,  through  which  the  vapour  can  be  readily 
inhaled.  If  I find  I am  likely  to  be  giving  the  chloroform  for  a long 
time,  I use  the  apparatus,  both  for  the  sake  of  convenience,  and  also 
of  economy,  as  5j  will  last  me  nearly  or  quite  an  hour  with  this ; 
and,  should  I use  it  many  hours,  it  not  only  effects  a great  saving  of 
material,  but  does  not  so  frequently  require  replenishing,  and  is 
always  ready  at  the  approach  of  each  separate  uterine  action ; and 
it  may  (as  has  been  the  case  with  me)  be  used  by  any  friends,  or  by 
the  nurse,  should  the  practitioner  require  to  be  absent  for  a short 
time.  The  other  apparatus  is  an  inhaler,  such  as  is  commonly  sold  ; 
it  is  made  of  a thin  and  pliable  lead,  adapted  over  the  nose  and 


236 


APPLICATIONS  IN  MIDWIFERY. 


mouth,  having  a piece  of  perforated  zinc  in  its  front,  and  containing 
a piece  of  sponge,  over  which  the  chloroform  is  thrown  : the  depth 
of  this  inhaler  is  such  as  to  prevent  the  nose  being  touched  by  the 
chloroform.  It  is  home  manufactured,  not  expensive,  and  very  easy 
of  construction.  This  latter  I make  use  of  if  I am  likely  to  be 
wanting  it  for  a short  time  only ; it  requires  to  be  supplied  afresh 
every  five  or  ten  minutes,  and,  accordingly,  I use  5j  or  5ss,  which 
latter  is  my  quantity  when  about  to  extract  a tooth.  If  the  action 
of  the  uterus  causes  great  pain,  as  is  frequently  the  case  in  an  early 
period  of  the  labour  with  the  first  child,  I commence  giving  it  as 
soon  as  the  os  uteri  is  sufficiently  dilated  for  the  head  to  pass ; I 
have  given  it  when  the  opening  has  not  exceeded  the  size  of  half-a- 
crown.  I believe  it  may  be  given  with  impunity  as  early  in  the 
labour  as  we  please,  and  the  only  obstacles  to  its  being  so  used  that 
I can  see,  are  the  inconvenience  to  the  medical  attendant  in  being 
thus  occupied  with  one  patient  for  such  a length  of  time,  and  also 
■ the  very  great  expense  which  such  a lengthened  use  of  it  must  entail. 
On  the  patient’s  account,  I can  see  no  possible  reason  why  it  may 
not  be  used  for  a whole  day,  or  even  more ; indeed,  I cannot  see 
why  a limit  should  be  set  to  the  length  of  time  in  which  it  may  be 
used.  I have  no  doubt  but  that  it  will  soon  be  the  anodyne 
generally  used  at  the  latter  stages  of  painful  cancerous  diseases. 
The  greatest  length  of  time  in  which  I have  used  it  has  been  16^ 
hours,  a fresh  inhalation  being  made  at  every  renewal  of  the  action 
of  the  uterus;  in  other  cases,  I have  given  it  11 J and  12  hours, 
and  the  only  reason  of  the  inhalation  being  limited  to  this  time,  has 
been  the  cessation  of  the  necessity  for  its  use,  namely,  that  the  child 
has  been  born,  otherwise  it  would  have  been  continued  until  such 
event  had  taken  place. 

“ I haye  found  that  nearly  all  my  patients  have  recovered  very 
rapidly  ; most  of  those  who  have  had  children  previously,  have  been 
astonished  at  the  unusual  rapidity  of  their  recovery. 

“ I find  no  difference  as  to  the  expulsion  of  the  placenta  and  the 
subsequent  discharge,  when  administering  chloroform,  to  what  takes 
place  in  the  usual  natural  labour.  I have,  upon  two  occasions,  used 
it  for  very  severe  after-pains — pains  so  severe  that  their  cries  could 
be  heard  at  a considerable  distance ; indeed  they  appeared  worse 
than  the  pains  of  actual  labour ; in  both  cases  the  pain  was  com- 
pletely subdued  by  its  use.  Both  these  persons  had  determined  not 
to  avail  themselves  of  the  benefit  of  the  chloroform  during  labour, 
neither  did  they,  but  they  were  delighted  afterwards  with  its  sooth- 


OPINIONS  OF  PRACTITIONERS. 


237 


ing  effects.  The  former  of  these  I had  long  resolved  to  give  it  to 
for  this  express  purpose  ; it  was  her  thirteenth  child  ; her  labours 
have  always  been  very  rapid,  scarcely  any  pain  accompanying  them ; 
but  no  sooner  has  the  child  been  born  than  her  agony  has  been 
almost  past  bearing,  the  pain  recurring  at  intervals  for  a fortnight. 
Upon  this  occasion  I gave  it  to  her  three  times  within  the  first 
ten  hours,  and  she  had  nothing  to  complain  of  afterwards. 

“ As  regards  sickness,  I have  not  found  that  symptom,  except 
where  fluid  has  been  previously  taken  ; on  the  contrary,  if  the 
patient  has  been  sick,  the  chloroform  has  almost  invariably  checked 
it.  The  cramp  I have  not  heard  them  suffer  from  whilst  under  its 
influence.  I have  never  yet  met  with  anything  which  has  caused 
me  to  regret  having  used  it. — Yours,  etc. 

‘‘  J.  G.  Lansdowne.” 

During  the  course  of  last  winter  and  spring,  the  practice  of 
ancesthesia  in  midwifery  was  tried  in  London  by  a very  intelligent 
young  Eussian  physician.  Dr.  Haartman  of  Helsingfors,  Avhile,  for 
the  sake  of  information,  he  was  living  as  house-surgeon  in  the  great 
Lying-in  Hospital  at  Westminster.  Dr.  Haartman  subsequently 
visited  Edinburgh,  and  kindly  drew  up  for  me,  before  leaving 
England,  the  following  account  of  the  results  of  his  practice.  I have 
much  pleasure  in  publishing  his  letter,  both  on  account  of  its  own 
intrinsic  value,  and  because  the  results  of  the  practice  of  anaesthesia 
in  this  Hospital  have  been  in  no  small  degree  misrepresented,  both 
publicly  and  privately. 

RESULTS  OF  ANESTHESIA  IN  THE  WESTMINSTER  LYING-IN 
HOSPITAL.^ 

“ I fulfil  with  the  greatest  pleasure  your  Avish,  in  writing  down 
my  observations  on  chloroform  as  used  in  midAvifery.  I do  it 
certainly  not  Avithout  much  embarrassment,  the  greater  the  more  I 
think  of  my  ignorance  of  the  English  idiom ; but,  encouraged  by 
your  indulgence,  I do  not  hesitate  to  begin  the  task,  more  especially 
as  I know  that  some  erroneous  ideas  of  the  use  of  the  chloroform  in 
the  General  Lying-in  Hospital  in  London  haA^e  been  spread  about. 

“ During  the  three  months  T was  house-surgeon  in  that  hospital, 
I had  the  opportunity  of  observing  105  Avomen  in  labour,  of  whom 
about  25  were  attended  by  my  friend  Dr.  Delafield  of  Hew  York, 

^ From  Edinburgh  Monthly  Journal  of  Medical  Science,  October  1848,  p.  225. 


238 


APPLICATIONS  IN  MIDWIFERY. 


the  other  80  by  myself.  But  having  been  most  of  the  time  the 
only  house-surgeon,  and  otherwise  much  engaged,  I was  not  able  to 
exhibit  the  chloroform  oftener  than  in  25  cases,  which,  I need 
scarcely  say,  were  in  no  way  selected.  The  most  of  these  patients, 
were,  however,  primiparce.  In  the  administration  of  the  chloroform 
I followed  your  method,  using  simply  a towel,  upon  the  interior  of 
which  the  liquid  was  diffused ; but  I held  it  as  a rule  to  exhibit  it 
in  the  beginning  of  each  case  rather  in  small  doses,  and  with  caution, 
watching,  in  the  meantime,  the  pulse,  as  the  surest  indicator  of  any 
danger.  But  when  the  patient  got  accustomed  to  it  I gave  it 
freely,  not  removing  the  tow'el  till  the  patient  was  in  deep  sleep. 
In  this  state,  the  respiration  was  in  general  sonorous,  sometimes 
stertorous ; the  pupils  were  usually  somewhat  contracted ; sometimes, 
however,  dilated  ; sometimes  not  at  all  affected.  The  pulse  was,  in 
the  beginning,  either  a little  accelerated,  or  quite  natural,  I think, 
when  the  patient  was  not  frightened.  Yet  I have  seen  the  pulse, 
without  any  bad  consequence,  go  down  to  40,  when  the  chloroform 
was  used  for  a long  time  or  in  large  doses.  Its  strength  was  very 
seldom  altered,  being  then  weaker.  The  patient  usually  lay  quiet, 
all  the  muscles  being  relaxed  till  the  uterine  contractions  came  on, 
during  which  they  all,  with  few  exceptions,  pressed  down  as  in 
common  labour.  Some  of  them  complained,  although  they  after- 
ward said,  ‘ they  felt  no  pain  whatever.’  Few  talked  or  laughed, 
except  the  Irishwomen,  whom  I found  rather  refractory  to  the 
anaesthetic  influence,  probably  because  they  are,  in  general,  too  much 
accustomed  to  drinking  spirits.  All  the  cases  were,  with  few  ex- 
ceptions, observed  with  the  greatest  care,  and  both  the  duration,  the 
frequency,  and  the  nature  of  each  uterine  contraction,  both  before 
and  after  the  chloroform  was  exhibited,  were  marked  down.  Thus 
I find,  by  comparing  all  my  annotations,  arranged  in  tables,  that 
during  the  full  effect  of  the  chloroform  the  uterine  contractions 
became  less  frequent,  and,  I should  say,  less  powerful,  but,  when  the 
effect  had  passed  off  a little,  they  then  became  more  frequent  and 
shortened  in  duration  ; for  example,  if  the  interval  between  two 
uterine  contractions  before  the  use  of  the  chloroform  was  G minutes, 
and  the  duration  of  each  1^  minute,  both  these  periods  were  re- 
duced after  its  exhibition.  The  interval,  from  6 to  5,  4,  or  2 
minutes,  and  the  duration  of  each  pain  from  to  1 or  J minute. 
Besides,  I think  that  in  this  state  the  uterine  contractions  in 
general  came  on  more  suddenly  than  in  common  labour,  a circum- 
stance which,  however,  may  depend  on  an  illusion,  by  the  absence 


OPINIONS  OF  PRACTITIONERS. 


239 


pf  pain  existing  and  announcing  the  action  of  the  uterus  in  the 
usual  labour.  I have  never  observed  the  uterine  contractions  quite 
arrested,  yet  often  somewhat  delayed.  The  supposed  relaxation  of 
the  soft  parts  seems  to  me  at  least  uncertain  and  accidental.  In 
two  cases  in  which  I thought  the  chloroform  had  very  much  re- 
laxed the  rather  rigid  parts,  I had,  notwithstanding,  rupture  of  the 
perineum.  Among  the  25  cases  of  chloroform,  I had  only  in  one  a 
slight  hemorrhage — a fact  the  more  remarkable,  as  at  the  epoch  at 
which  I used  chloroform  most  frequently,  I can  say  I had  hemor- 
rhage, and  that  often  very  severe,  in  almost  all  the  other  cases  in 
which  chloroform  was  not  used. 

“ After  the  delivery,  I found  the  patient  in  general  quite  un- 
conscious of  any  occurrence  during  the  anaisthetic  state,  some  of 
them  saying,  nevertheless,  that  they  had  felt  something  going  on, 
although  they  did  not  know  what.  They  seldom  complained  of 
headache,  and  it  usually  disappeared  during  the  following  day.  The 
mothers  recovered  all  speedily  and  perfectly,  with  one  exception, 
worthy  your  attention,  although  I am  fully  convinced  that  the 
accident  by  no  means  was  the  result  of  the  chloroform,  of  which 
only  two  drachms  were  used — my  provision  at  that  time  not  being 
larger.  During  the  use  of  the  chloroform  this  patient  was,  as  usual, 
insensible  and  quiet ; but,  for  want  of  chloroform,  the  effect  could 
not  be  kept  up  for  a long  time,  and  she  was  delivered  with  the 
usual  pains.  She  was  the  following  day  perfectly  well,  and  continued 
so  till  the  eighth  day  after  the  delivery — she  had  then  complained  to 
the  other  patients  of  headache.  I was,  however,  not  called  for, 
before  she,  in  the  afternoon,  had  had  a fit  of  what  is  commonly 
called  apoplexia  nervosa,  after  which  she  got  paralytic  on  the  right 
side.  I need  not  give  you  a tedious  description  of  the  proceeding 
and  the  treatment  of  the  disease  ; allow  me  only  to  state  that  the 
patient  began,  by  the  use  of  strengthening  medicine,  to  walk  about 
in  a month.^ 

“Of  all  the  105  children,  six  were  either  still-born,  or  died 
sooner  or  later  after  the  birth — two  only  of  them  belonging  to 
the  twenty- five  cases  of  chloroform.  But,  before  I relate  these  cases, 

1 The  “ puerperal  paralysis  ” was  in  this,  as  it  is  in  most  other  cases,  probably 
connected  with  albuminuria.  One  of  my  patients,  wlio  was  confined  for  the 
second  time  four  months  since,  was  attacked  two  years  ago  Avith  hemiplegia  im- 
mediately after  the  birth  of  her  first  child.  I have  a patient  at  present  under  my 
care,  from  Forres,  who  several  years  ago  was  attacked  with  hemiplegia  at  the 
time  of  delivery. 


f 


240  ArPLICATIONS  IN  MIDWIFERY. 

I beg  permission  to  point  out  some  general  remarks.  In  the^ 
majority  of  the  cases  I could  not  discover  any  change  whatever 
upon  the  child,  some  of  the  children  being  rather  bloodfull,  others 
anemic — states  depending,  I think,  as  usual,  on  the  duration  and 
the  nature  of  the  labour.  In  one  case,  however,  in  which  Dr. 
Fergusson  was  present,  the  newly-born  infant  was  found  rather 
strange,  or  to  use  the  eminent  doctor’s  expression  ‘tipsy.’  It 
breathed  less  frequently  and  more  abruptly  than  usual,  the  sound  of 
its  scream  being  rather  singular.  It  recovered,  nevertheless,  per- 
fectl}’'.  I must  here  observe  that  the  mother  (Irish),  who,  after  the 
confinement,  had  brought  up  a large  quantity  of  gin  and  broom, 
confessed  having  taken  spirits  before  admittance  into  the  hospital. 
Of  the  two  children  who  died,  the  first  was  rather  weak  and  thin, 
but  continued  pretty  well  till  the  seventh  day,  when  it  got  peri- 
tonitis, and  died  on  the  tenth  day  after  birth.  The  second,  a large 
and  fat  child,  died  four  hours  after  birth  ; in  this  case,  when  the 
head  was  born,  I observed  around  the  neck  small  blue  spots,  which 
I found  to  be  blood  extravasated  under  the  skin.  After  birth  the 
same  kind  of  spots  began  to  appear  over  nearly  the  whole  of  the 
body.  The  child  breathed  well  in  the  beginning,  but  wmuld  not 
suck.  It  died  without  convulsions.  By  the  post  mortem  examina- 
tion, the  spots  were  found  to  be  blood  extravasated  from  the  capillary 
vessels  of  the  skin ; a large  quantity  of  half-coagulated  blood  was 
found  in  the  cavity  of  the  peritoneum,  and  small  blood-coagula  in 
both  lateral  ventricles  of  the  brain.  The  lungs  and  the  brain  were 
slightly  congested.  The  blood  seemed  to  be  quite  natural,  and  had 
no  anormal  smell.^ 

“ Before  I finish,  I beg  to  add  that  I have  used  the  chloroform 
in  a case  of  turning  with  the  greatest  advantage.  I was  called  out 
from  the  hospital  to  a poor  woman  in  labour,  and  found  a presenta- 
tion of  the  cord,  and  the  uterus  so  contracted  that  I could  nowhere 
introduce  my  hand,  although  I made  repeated  attempts  without 

^ This  special  case  of  purpura  has  been  often  mentioned.  Every  one  aequainted 
with  infantile  pathology  knows  that  purpura  is  not  a rare  occurrence  at  birth,  as 
the  cases  and  observations  of  Andral,  Billard,  Otto,  Lobstein,  and  Graetzer,  etc., 
amply  prove.  A patient  who  came  some  time  ago  from  London,  to  be  confined 
in  Edinburgh,  under  my  care,  was  gravely  assured  by  a distinguished  London 
physician,  that  if  chloroformed,  her  child  would  be  sure  to  be,  as  they  all  were  in 
the  Westminster  Hospital,  “ either  dead-born,  or  with  their  blood  in  a putrid  and 
dissolved  state  ! ” The  want  of  the  head  in  the  anencephalic  child  born  at 
Dundee  (see  Dr.  Patou’s  letter,  p.  230),  might  have  been  as  logically  ascribed  to 
the  mother’s  use  of  chloroform,  as  the  purpura  in  the  above  instance. 


OPINIONS  OF  PRACTITIONERS. 


241 


success.  I then  gave  a large  quantity  of  chloroform,  and  I was 
quite  astonished  at  the  great  change  which  took  place,  it  being  now 
uncommonly  easy  to  perform  the  turning. — Yours,  etc. 

“Charles  de  Haartman.” 

Of  the  use  of  chloroform  in  midwifery  in  Ireland,  I have  few 
details.  From  Dublin,  my  friend  Dr.  Tyler  wrote  me,  in  June  last, 
that  the  practice  has  not  yet  been  much  tried.  He  observes — 

“ As  to  the  progress  of  chloroform  in  obstetric  practice  here,  I 
regret  to  state  that  its  virtues  have  not  yet  been  fairly  put  to  the 
test  by  any  of  our  Dublin  accoucheurs,  owing  to  a dread  of  bad  conse- 
quences resulting,  although  I am  unaware  of  any  case  followed  by  such 
being  brought  home  to  it,  except  a rumoured  one  of  threatened 
convulsions  and  spasms,  where was  administering  it. 

“ As  to  the  surgeons,  I hear  them  all  speak  in  the  highest  terms 
of  it.  The  resident  surgeon  of  Stevens’s  Hospital,  Mr.  Wilmot,  told 
me  yesterday  that  he  administers  it  previously  to  every  operation 
there,  now  in  some  hundred  cases,  without  meeting  with  any 
untoward  result. — Yours,  etc.  A.  Tyler.” 

Subsequently,  Dr.  Tyler  informed  me  that  Mr.  Shekleton,  master 
of  the  great  Dublin  Lying-in  Hospital,  was  trying  the  effects  of 
chloroform ; and,  at  a still  later  date.  Dr.  Denham,  assistant  phy- 
sician in  that  hospital,  while  on  a visit  to  Edinburgh,  informed  me 
that  Mr.  Shekleton  had  now  exhibited  chloroform  in  upwards  of 
forty  cases  of  labour,  most  of  them  of  an  operative  or  instrumental 
kind,  and  that  the  effects  had  been  such  as  to  induce  him  to  go 
on  with  the  trial  of  it.  No  unfavourable  results,  either  as  regards 
the  mothers  or  children,  have  been  observed  to  follow  the  use 
of  chloroform.  Som.e  of . the  principal  private  practitioners  in 
Dublin  are  also.  Dr.  Denham  informs  me,  beginning  to  employ  the 
practice. 

Eegarding  the  use  of  chloroform  in  midwifery  on  the  Continent 
of  Europe,  I possess  little  or  no  information.  Dr.  Krieger,  of 
Berlin,  tells  me  that  in  that  city  most  medical  men  are  opposed  to 
the  practice  of  anaesthetic  midwifery,  but  still,  five  or  six  accou- 
cheurs constantly  make  use  of  it.  Writing  to  me  in  July  last.  Dr. 
Krieger  says — 

“ About  five  or  six  accoucheurs  of  this  place,  I don’t  think  there 
will  be  more  of  them,  use  chloroform  in  almost  every  case  they 


242 


APPLICATIONS  IN  MIDWIFERY. 


attend ; many  more  only  in  cases  of  morbid  labour ; the  majority 
not  at  all.  The  cause  of  this  curious  occurrence — curious,  because 
in  every  surgical  operation  chloroform  is  made  use  of — may  be  found, 
not  only  in  the  disinclination  of  the  public  at  large  to  such  extra- 
ordinary means  in  quite  a natural  process  (as  they  take  labour  for), 
but  perhaps  also  in  the  expense,  chloroform  being  still  a costly 
article.  I don’t  know  whether  the  preparation  we  get  here  is  less 
strong  than  it  ought  to  be,  or  not,  but  I seldom  require  less  than 
six  drachms  or  an  ounce,  sometimes  more,  for  one  delivery,  and  the 
price  is  as  much  as  half-a-crown  per  ounce  at  apothecaries’  shops. 
Professor  Martin  of  Jena  has  used  ether  in  seven,  chloroform  in  ten 
cases  of  morbid  labour,  and  cannot  strongly  enough  recommend  the 
latter  anaesthetic  agent,  stating  that  he  never  witnessed  but  favour- 
able consequences.  I am  sorry  I cannot  give  you  any  more  details 
about  the  progress  chloroform  has  made  in  Germany — but  the 
perplexing  political  affairs  have  so  very  bad  an  influence  on  scientific 
publications,  that  we  get  but  very  little  medical  news  from  anywhere 
on  the  Continent,  and  those  only  such  as  were  long  prepared  before 
we  fell  victims  to  revolutions. — Yours,  etc.  E.  Krieger.” 

In  a letter  which  I have  lately  received  from  Vienna,  the  writer. 
Dr.  Arneth,  informs  me  that  the  use  of  anaesthetic  agents  in  mid- 
wifery is,  as  a general  rule,  discountenanced  in  that  city  by  the  two 
leading  professors  of  midwifery  in  the  University,  but  that,  in  several 
late  cases,  they  have  used  it  in  operative  delivery.  He  further  states, 
that  in  Wurzburg,  the  use  of  chloroform  in  obstetric  practice  is  more 
common.  He  states — 

“ While  I am  writing  this  letter.  Professor  Kiwisch,  of  Wiirzburg, 
tells  me  that  in  that  place  no  woman  is  confined,  neither  in  private 
nor  in  hospital  practice,  without  having  been  chloroformed.  In  two 
cases  of  eclampsy,  he  saw  decided  effect  of  these  vapours — viz.  the 
fits  subsided. — Yours,  etc.  F.  H.  Arneth.” 

The  preceding  kind  of  evidence,  in  relation  to  the  practice  of 
anaesthesia  in  midwifery,  in  tliis  and  other  countries,  might,  as  I 
have  already  stated,  be  very  easily  increased  and  multiplied  by  a 
little  more  extended  inquiry,  and  by  an  appeal  to  the  experience  of 
the  numerous  accoucheurs  here  and  elsewhere  that  have  employed 
it.  But  the  evidence  as  it  stands — and  spontaneous  as  it  is  in  most 
cases — is  amply  sufficient  to  show  both  the  great  extent  to  which 


OPINIONS  OF  PRACTITIONERS. 


243 


the  new  practice  has  already  been  adopted,  and  the  great  success 
that  has  attended  it.  Every  innovation  in  medicine  which  implies, 
like  the  present,  a violent  and  extensive  change  in  existing  doctrines 
and  old-established  practices,  has  always  been,  for  a length  of  time 
after  its  introduction,  stoutly  decried  and  resisted.  The  history  of 
the  first  introduction  and  subsequent  progress  of  the  three  greatest 
modern  improvements  in  practical  surgery,  midwifery,  and  medicine 
— viz.  the  ligature  of  arteries,  the  induction  of  premature  labour, 
and  the  discovery  of  vaccination — afford  sad  but  strong  historical 
proof  of  this  observation  ; and  we  have  many  minor  instances  of  the 
same  constant  enmity  to  change,  in  the  bitter  opposition  which  the 
first  employment  of  antimony,  ipecacuanha,  cinchona  bark,^  and 
other  medicines  encountered.  And  I believe  that  I am  correct  in 
stating  that  probably  no  innovation,  embodying  so  very  direct  and 
decided  a deviation  from  all  the  former  routine  and  rules  of  practice, 
as  the  employment  of  ansesthesia  in  midwifery  implies,  ever,  in  the 

^ The  London  physicians  have,  on  .several  occasions,  specially  distinguished 
themselves  by  their  determined  and  prejudiced  opposition  to  all  innovations  in 
practice  not  originating  among  themselves.  In  the  whole  pharmacopeeia,  there 
is  perhaps  no  one  remedy  which,  at  the  present  day,  is  acknowledged  to  be  of 
greater  value,  or  to  have  saved  more  human  lives,  than  cinchona  and  its  prepara- 
tions. In  the  seventeenth  century,  the  proper  time  and  manner  of  using  the 
cinchona  bark,  for  the  cure  of  the  then  prevalent  intermittent  fevers  of  England, 
was  made  out  by  Robert  Talbor,  a medical  practitioner  in  Essex.  AVhen  Talbor 
subsequently  removed  to  London,  and  began  to  use  with  success  the  new  remedy, 
in  the  cure  of  the  common  agues  of  the  metropolis,  he  found  that,  as  he  gained 
in  the  favour  of  the  world,  he  lost  that  of  the  physicians  of  London  ; and  ap- 
parently their  persecution  of  him  became  such,  that  the  King  at  last  was  obliged 
to  interfere,  and  in  the  year  1678,  King  Charles  II.  sent  a royal  mandate  to  the 
College  of  Physicians,  commanding  the  president.  Dr.  Micklethwait,  “ and  the 
rest  of  the  College  of  Physicians,”  not  to  give  Talbor  “ molestation  or  disturbance 
in  his  practice.”  Among  the  list  of  London  physicians  averse  to  the  new 
practice  of  curing  ague  by  cinchona  bark,  De  Bergen  mentions  the  illustrious 
names  of  Sydenham,  Harvey,  etc.  In  1698,  a Dutch  physician,  Dr.  Groenvelt, 
published  a work  entitled,  De  tuto  cantharidis  in  medicina  usu  intcrno.  A few 
years  previously — viz.  in  1693,  when  Groenvelt  practised  in  London — the  President 
of  the  College  of  Physicians  imprisoned  him  in  Newgate  for  daring  to  recommend 
and  use  the  new  remedy  whose  virtues  he  had  discovered.  Six  or  seven  years  after 
vaccination  began  to  be  generally  used  throughout  England,  Dr.  Moseley,  a 
member  of  the  London  College  of  Physicians,  suggested  to  his  College  the  i^ro- 
priety  of  putting  down  “ the  beastly  new  disease,”  as  it  was  termed,  of  cow-pox  ; 
and  in  1805,  he  boasted  that  the  middle  and  inferior  classes  of  London  had  tlien 
“renounced  the  delusion.”  In  the  last  number  of  a respectable  London  medical 
journal,  a London  medical  practitioner  questions  whether  the  practice  of  relieving 
women,  by  anaesthetics,  from  the  pains  and  agonies  of  parturition,  should  not 
“be  considered  criminal  according  to  law.” — See  Lo'>rdon  Medical  Gaze-lie  for 
Sept.  8,  p.  424. 


244 


APPLICATIONS  IN  MIDWIFEKY. 


same  short  period,  made  such  extensive  way  aind  progress  as  it  has 
done  among  the  profession.  As  a matter  of  course,  however,  it  has 
called  forth  also  abundance  of  published  and  unpublished  opposition 
and  objection.  No  small  share  of  the  resistance  against  it  has  taken 
the  form  of  personal  or  professional  abuse  of  me  as  the  introducer  of 
the  practice.  All  that  I most  willingly  pass  over  and  excuse,  as, 
judging  from  all  past  experience  in  medicine,  it  was  nothing  more 
nor  less  than  I was  entitled  to  expect  under  the  circumstances. 


RESULTS. 


245 


CHAPTER  V. 

RESULTS  OF  THE  PRACTICE  OF  ANiESTHESIA  IN  MIDWIFERY. 

Edinburgh,  October  1848. 

Since  January  1847,  up  to  the  present  time  (October  1848),  I have, 
in  my  own  practice,  delivered  about  150  patients  under  a state  of 
anaesthesia.  The  results  to  the  children  and  mothers  have  been  as 
follows  : — 

Results  to  the  Children. — In  the  150  cases,  all  the  children  were 
born  alive  except  one.  In  this  exceptional  instance,  the  infant  was 
expelled  in  a decomposed  and  putrid  state,  between  the  seventh  and 
eighth  month  of  utero-gestation.  It  had  not  been  felt  to  move,  nor 
had  I been  able  to  hear  the  foetal  heart  with  the  stethoscope,  for 
two  or  three  weeks  previously.  The  mother  had,  before  the  present 
pregnancy,  borne  several  premature  dead  children.  Though  the 
infant  was  small,  yet  the  suffering  attending  upon  its  expulsion 
threatened  to  be  excessive,  and,  to  relieve  the  mother  of  this  unne- 
cessary  agony,  I placed  her  under  the  influence  of  chloroform. 

During  the  few  weeks  of  my  obstetric  attendance  after  delivery 
upon  these  150  cases,  only  one  of  the  children  died — namely,  a child 
who  sank  under  the  symptoms  of  cyanosis.  Nor  am  I aware  that 
any  of  them  has  suffered,  up  to  this  time,  from  “ cerebral  effusions,” 
or  “ convulsions,”  or  “ hydrocephalus,”  or  any  other  of  the  affections 
which  have  been  prophesied  as  certain  to  befall  all  such  infants  as 
would  be  borne  in  labours  rendered  painless  by  art.  Perhaps  it  may 
be  proper  to  add,  that  none  of  the  children  have  shown  any  symptoms 
of  what  has  been  calmly  averred,  in  more  than  one  publication  in 
London,  as  a possible,  or  rather  probable,  result  of  anaesthesia — viz. 
idiocy. — “Dixerit  insanum  qui  te,  totidem  audiet.”^ 

’ How  can  we  “ know  or  ascertain  the  possible  consequences  of  the  use  of  such 
an  agent  on  the  brain  of  the  child  ? And  how  can  we  calculate  what  may  he  the 
ultimate  consequences  of  its  action  in  reference  to  the  development  of  the  mental 
faculties  ?” — Dr.  Malan,  in  Lancet  for  April  29,  1848. 

“ It  is  admitted  by  all  that  the  pulsations  of  the  foetal  heart  are  greatly  increased 
during  inhalation — indeed,  to  such  an  extent  has  this  been  noticed,  tJiat  in  some 
instances  the  pulsations  could  not  be  counted,  so  much  were  they  accelerated. 


246 


APPLICATIONS  IN  MIDWIFERY. 


Results  to  the  Mothers. — Among  the  150  mothers,  the  more  im- 
mediate and  direct  effect  of  anaesthesia  has  been  the  alleviation  or 
abolition  of  the  physical  sufferings  attendant  upon  the  latter  stages 
of  labour.  And,  certainly,  if  the  object  of  the  medical  practitioner 
is  really  twofold,  as  it  has  always,  till  of  late,  been  declared  to  be — 
viz.  “ the  alleviation  of  human  suffering  and  the  preservation  of 
human  life,” — then  it  is  our  duty,  as  well  as  our  privilege,  to  use  all 
legitimate  means  to  mitigate  and  remove  the  physical  sufferings  of 
the  mother  during  parturition.  The  degree  of  these  sufferings  is,  as 
a general  rule,  assuredly  such  as  to  call  for  this  aid  and  mitigation. 
In  proof  of  their  severity,  I might  cite  the  unprejudiced  testimony 
of  various  obstetric  authors.  At  present,  I shall  content  myself  with 
one.  Professor  Meigs  of  Philadelphia — a declared  opponent  of  the 
innovation  of  artificial  anaesthesia  in  labour — when  speaking  of  the 
sufferings  of  the  mother  in  human  parturition,  fully  admits  their 
intensity.  “ What  (says  he)  do  you  call  the  pain  of  parturition  ? 
There  is  no  name  for  it  but  Agony  and  he  elsewhere  speaks  of 
the  pains  in  the  last  stage  “ as  absolutely  indescribable,  and  com- 
parable to  no  other  pains.”  ^ Now,  surely,  if  it  be  the  duty  of  the 
physician  (and  who  doubts  it  ?)  to  relieve  and  remove  the  pains  of 
colic,  of  pleurodyne,  of  headache,  neuralgia,  rheumatism,  etc.  etc.,  it 
is  his  duty  to  relieve  pain  so  severe  as  to  be  “ absolutely  indescrib- 
able, and  comparable  to  no  other  pains.”  There  is  not  one  code  of 
humanity  for  one  class  of  pains  and  patients,  and  a different  and 
opposite  code  for  another  class  of  them. 

From  November  last,  when  I began  to  use  chloroform  in  labour, 
up  to  the  present  time,  none  of  the  patients,  with  one  exception,  at 

Are  not  effusions  to  be  feared  from  this  ? Are  not  convulsions  after  birth  likely 
to  ensue  ? And  may  not  that  occur  which  would  make  the  most  heartless  mother 
shudder  at  the  bare  possibility  of  herself,  by  her  want  of  courage,  being  instru- 
mental in  producing  ? May  not  Idiocy  supervene  ? Of  this  we  have  as  yet  no 
experience,  nor  shall  we  have,  perhaps,  for  years  ; but  when  one  such  case  occurs, 
will  there  then  be  found  any  one  who  will  afterwards  be  persuaded  to  submit  her- 
self to  etherisation  during  pregnancy  ?” — Mr.  Gream,  in  London  Medical  Gazette 
for  7th  September  1848.  It  is  perhaps  superfluous  to  add,  that  the  premises  of  the 
preceding  paragraph  are  as  gratuitous  as  its  conclusions  ; and  that  the  pulsations 
of  the  fcetal  heart  are  little,  if  at  all,  increased  in  rapidity  when  the  mother  is 
anaesthetised.  “The  action  of  the  child’s  heart,”  says  Professor  Siebold,  “was 
found  to  continue  quite  unaltered,  not  the  slightest  change  in  its  frequency  and 
regularity  being  detected.” — Siebold  on  the  Employment  of  Ethereal  Inhalations 
in  Midwifery,  in  the  Medical  Gazette  for  IJth  June  1847. 

^ Females  and  their  Diseases,  p.  49.  I leave  the  italics  the  same  as  in  the 
original. 

2 Philadd2}hia  Practice  of  Midwifery,  p.  153. 


RESULTS. 


247 


whose  delivery  I have  attended,  has  been  aware  of  these  last  “ abso- 
lutely indescribable”  pains;  the  state  of  artificial  ansesthesia  having 
always  been  induced  for  a longer  or  shorter  time  before  their  super- 
vention. And  I have  kept  up  this  state  for  a period  varying  from 
a few  minutes  to  four,  five,  six,  or  more  hours  before  delivery.  In 
the  exceptional  case  referred  to,  the  patient’s  sufferings  were  greatly 
mitigated  ; but  the  state  of  anjesthesia  was  not,  as  usual,  perfect  and 
complete,  the  patient  having  been  unexpectedly  taken  in  labour 
when  not  in  her  own  house,  and  the  attendant  anxiety  and  con- 
fusion of  herself  and  her  attendants  being  such  as  totally  to  preclude 
the  requisite  degree  of  quietude.  When  employing  ether,  I repeat- 
edly saw  cases  in  which  the  patients  were  thus  only  partially  and 
not  completely  anaesthetised — where,  in  other  words,  they  were  not 
entirely  asleep,  but  were  aware  of  the  presence  of  the  uterine  con- 
tractions, and  sometimes  experienced  from  them  sensations  in  some 
degree  painful,  but  of  a very  mitigated  and  blunted  character. 

Besides  thus  alleviating  and  abolishing  the  sufferings  of  the 
mother  during  labour,  the  practice  of  anaesthesia  carries  along  with 
it  other  advantages.  A number  of  patients  have  spontaneously  told 
me,  that  the  prospect  of  being  enabled  to  pass  through  the  ordeal  of 
parturition  with  the  assistance  of  anaesthetic  agents,  and  Avithout 
their  usual  painful  agonies,  has  destroyed,  in  a great  measure,  that 
state  of  anxiety  and  dread  of  anticipation,  Avhich,  in  former  preg- 
nancies, had,  for  w^eeks  and  months  previously,  silently  annoyed  and 
haunted  them.  If  we  can  thus  add  to  the  happiness  of  our  patients, 
by  imparting  to  them  feelings  of  safety  and  immunity  under  one  of 
the  severest  trials  to  which  nature  exposes  them,  Ave  surely  folloAV 
out,  in  its  truest  sense,  that  Avhich  Dr.  Meigs  correctly  describes  as 
the  office  of  a physician — namely,  “ a great  mission  of  benevolence 
and  utility.” 

But  the  practice  of  anjesthesia  in  midAvifery  not  only  saves  the 
mother  from  the  endurance  of  unnecessary  mental  anxiety  and  un- 
necessary physical  agony  ; it  saA^es  her  also  from  some  of  the  dangers 
attendant  upon  parturition,  by  husbanding  her  strength  and  Avarding 
off  the  effects  of  that  exhaustion  and  nervous  depression  Avhich  the 
pains  and  shock  of  delivery  tend  to  produce.  In  most  cases  the 
mothers,  after  delivery,  on  Avaking  from  their  anaesthetic  sleep,  have 
expressed  surprise  at  their  own  feelings  of  strength  and  perfect  Avell- 
being ; and  many,  Avho  have  borne  children  previously,  haA^e  grate- 
fully declared  to  me  the  great  difference  Avhich  they  have  found 
between  their  condition  after  being  delivered  under  anaesthetics, 
72 


248 


APPLICATIONS  IN  MIDWIFERY. 


and  without  pain  and  suffering,  and  their  state  of  prostration  after 
former  labours,  when  they  were  subjected  to  the  endurance  of  all 
the  usual  “ pangs  and  agonies”  of  parturition.  Nor  does  the  benefit 
end  here.  By  annulling  the  parturient  pains  and  shock,  and  their 
direct  and  primary  depressing  effects  upon  the  constitution,  we  ward 
off,  I believe,  to  a more  or  less  marked  extent,  the  chances  and 
dangers  of  those  secondary  vascular  excitements  which  are  always 
apt  to  follow  indirectly  upon  them.  We  increase  the  chances  of  a 
more  speedy  and  a more  healthy  convalescence.  And  both  patients 
and  practitioners  have,  as  a general  rule,  had  occasion  to  observe 
that  the  period  of  convalescence  has  been  evidently  curtailed  and 
shortened  by  the  previous  adoption  of  anaesthesia  during  delivery. 

Such  certainly  has  been  my  own  experience.  For,  since  follow- 
ing the  practice  of  anaesthesia,  my  strong  conviction  is,  that  I have 
seen  both  more  rapid  recoveries  than  formerly,  and  feAver  puerperal 
complications.  One  patient,  however,  had  a short  attack  of  peri- 
tonitis, requiring  leeches,  etc.  It  was  her  third  accouchement  and 
her  first  living  child ; and,  after  her  two  former  deliveries,  she  had 
required  to  be  bled,  and  treated  for  similar  inflammatory  attacks. 
At  her  first  labour  she  suffered  severely  from  puerperal  convulsions. 
In  two  others  of  my  patients  the  convalescence  Awas  delayed,  in  one 
by  an  attack  of  the  affection  described  by  Dr.  Marshall  Hall  as 
“ intestinal  irritation”  in  the  puerperal  female  ; and  in  the  other  by 
a fit  of  jaundice,  which  supervened  tAVO  or  three  Aveeks  subsequently 
to  delivery,  and  after  the  patient  had  been  for  several  days  in  the 
drawing-room.  In  December  and  January  last,  an  epidemic  of 
puerperal  fever  swept  fatally  over  Edinburgh  and  other  parts  of 
Scotland.  During  the  period  of  its  prevalence,  tAvo  of  my  patients 
Avere  seized  with  it  and  died.  But  the  previous  employment  of 
anaesthesia  in  these  cases  had  nothing  to  do  Avith  this  distressing 
result.  Some  of  my  professional  brethren  here  and  elsewhere,  Avho 
were  not  using  ether  or  chloroform,  were  much  more  unfortunate 
than  I Avas.  In  a district  in  the  neighbourliood  of  Edinburgh,  one 
of  the  medical  attendants  informed  me  that  at  that  time  above 
twenty  mothers  were  attacked  and  died,  and  in  none  of  them  Avhom 
the  disease  seized  upon  did  ether  or  chloroform  happen  to  be  used ; 
while  several  Avho  demanded  chloroform  during  their  labours  all 
fortunately  escaped.  The  first  of  the  tAvo  cases  Avhich  I met  with 
Avas  after  a second  labour.  The  patient’s  first  labour  Avas  extremely 
tedious  and  prolonged,  and,  at  last,  symptoms  supervened  Avhich 
demanded  the  delivery  of  the  child  by  the  forceps.  In  her  second 


RESULTS. 


249 


delivery,  the  labour  was  much  shorter ; the  second  stage  lasted  only 
for  about  twenty  minutes,  and  during  it  she  was  completely  anaes- 
thetised. Tor  fifty  hours  after  delivery  she  progressed  most  favour- 
ably ; and  after  seeing  her  at  that  time  with  a pulse  at  eighty,  and 
otherwise  well,  I was  suddenly  summoned,  in  consequence  of  ex- 
tremely severe  pain  having  come  on  in  the  uterine  region  after  some 
muscular  exertion.  Rigors,  rapidity  of  the  pulse,  tympanitis,  etc., 
supervened,  and  she  speedily  sank,  with  all  the  usual  symptoms  of 
puerperal  peritonitis.  The  second  case  alluded  to  was  in  a primi- 
para.  The  labour  was  tedious,  the  pain  severe,  and  the  patient  was 
ansesthetised  for  four  or  five  hours  before  delivery.  For  some  days 
after  delivery  she  went  on  prosperously,  until  she  became  unhappily 
and  greatly  excited  by  discovering  intemperate  habits  on  the  part  of 
the  monthly  nurse  who  was  taking  charge  of  her  infant  and  herself. 
A fit  of  convulsions  (a  disease  to  which,  in  earlier  life,  she  had  been 
long  subject)  immediately  supervened,  and  recurred  several  times. 
Fatal  febrile  symptoms  then  set  in,  with  tympanitis  and  excessive 
diarrhoea. 

I may  add  that,  in  the  period  during  which  these  150  cases  oc- 
curred, I have  had  under  my  professional  charge  20  or  30  other  cases 
of  labour  in  which  aneesthesia  was  not  employed,  from  the  rapidity 
and  facility  of  the  delivery,  from  the  patient  being  too  late  to  send 
for  assistance,  from  an  aversion  on  the  part  of  patients  to  the  use  of 
anaesthetics,  more  especially  when  ether  first  began  to  be  used  during 
last  year,  or  from  other  causes.’  One  of  the  children  in  these  cases 
was  still-born,  and  a second  died  two  or  three  days  after  delivery. 
Two  of  the  mothers  suffered  from  crural  phlebitis ; a third  had  a 
severe  attack  of  puerperal  fever,  but  recovered.  Two  others  died  ; 
one  of  them  under  an  attack  of  puerperal  convulsions  and  coma, 
'which  supervened  fourteen  days  after  delivery.^  In  the  other  fatal 
case,  the  patient,  who  had  suffered  much  in  her  previous  labours, 
came  to  the  immediate  neighbourhood  of  Edinburgh  to  be  confined, 
and  with  the  view  of  using  chloroform.  But  the  labour  proved  un- 
usually rapid,  and  she  was  delivered  before  the  call  for  assistance 
reached  my  house.  Her  recovery  went  on*  uninterruptedly  for  two 
weeks,  when  a severe  attack  of  dyspnoea  supervened.  My  friend  Pro- 
fessor Miller,  her  ordinary  medical  adviser,  saw  her  in  my  absence, 
and  suspected  some  acute  affection  of  the  heart.  When  we  visited  her 

^ Since  November  last  I have  used, chloroform  in  all  the  cases  of  labour,  where 
I have  been  called  in  time,  except  two. 

2 See  details  of  it  in  Monthly  Journal  for  1847,  p.  213. 


2^0 


APPLICATIONS  IN  MIDWIFERY. 


together  shortly  afterwards,  the  symptoms  .were  then  apparently 
those  of  acute  endocarditis.  She  was  submitted  to  the  usual  antb 
phlogistic  treatment,  and  in  four  or  five  days  felt  again  so  well  as 
to  insist  upon  being  allowed  to  rise,  which  was  forbidden.  In  the 
course  of  a few  hours  afterwards,  another  fit  of  dyspnoea  suddenly 
supervened,  and  before  Mr.  Miller  reached  the  patient’s  house,  she 
was  dead.  We  did  not  procure  an  autopsy.  If  unfortunately  she 
had  used  chloroform  during  the  labour,  as  was  her  intention  and 
wish,  many  of  the  objectors  to  its  employment  would  have,  I. fear, 
unhesitatingly  attributed  the  fatal  issue  in  this  case  to  its  previous 
employment.^ 

In  addition  to  the  150  cases  of  artificial  anaesthesia  that  have 
occurred  in  my  own  midwifery  practice,  and  to  which  the  preceding 
remarks  apply,  I have  witnessed,  during  the  last  eighteen  months,  a 
considerable  number  of  instances  in  which  anaesthetic  agents  were 
employed  in  consultation  and  hospital  practice  ; and  I have  fre- 
quently had  recourse  to  their  assistance  in  various  obstetric  opera- 
tions which  I have  been  called  upon  to  perform,  as  in  the  separation 
and  removal  of  the  placenta,  in  various  cases  of  turning,  in  one 
craniotomy  case,  and  in  several  patients  who  required  to  be  delivered 

^ In  order  to  show  the  caution  that  is  necessary  in  reasoning  upon  cases  of 
death  apparently  from  the  exhibition  of  chloroform  during  surgical  operations,  I 
may  add  that,  since  November  last,  scarcely  an  operation  has  been  performed  in 
Edinburgh  without  previous  anfesthesia,  except  where  the  throat  or  mouth  was 
the  seat  of  incisions,  or  the  operation  itself  slight  and  trivial.  Amid  all  the 
numerous  patients  thus  operated  on  in  public  or  private  practice,  when  under  the 
use  of  chloroform,  no  kind  of  misadventure  or  accident  has  happened  ; except  one 
case  of  temporary  fainting,  a few  minutes  after  recovery  from  the  state  of  anaes- 
thesia, be  regarded  as  such.  On  the  other  hand,  among  the  few  exceptional  cases 
in  which,  since  November  last,  patients  have  been  operated  on  in  this  city  with- 
out chloroform,  two  have  died  on  the  table.  One  of  the  two  was  being  operated 
on  by  Professor  Miller  for  a hernia,  which  had  been  strangulated  for  about  fifteen  * 
hours  ; when,  after  the  skin  merely  was  divided,  the  patient  complained  of  great 
faintness,  vomited,  and  died  with  the  operation  unfinished.  This  occurred  on  the 
8th  of  November,  two  or  three  days  after  the  anresthetic  effects  of  chloroform  were 
discovered,  and  nearly  proved  the  first  operation  in  which  it  was  tried.  The 
second  case,  a patient  of  Dr.  Pattision,  had  an  abscess  high  up  in  the  neck,  re- 
quiring simple  puncture  for  its  evacuation.  He  died  without  hemorrhage,  or 
admission  of  air,  or  other  apparent  cause,  a minute  or  two  after  the  puncture  was 
made.  If  chloroform  had  been  used  in  these  cases,  would  it  not  by  some  have 
been  blamed  for  the  result  ? 

Twelve  or  fourteen  months  ago.  Professor  Syme  was  performing  primary  am- 
putation of  the  thigh  in  the  hospit;  1,  upon  a patient  upon  whom  there  was  no 
simi  of  reaction,  and  who  was  not  etherised^ for  the  operation.  “Upon  the  inci- 
sions being  made,  relaxation  of  the  sphincters  took  place,  the  contents  of  the 
rectum  and  bladder  were  voided,  and  an  elfort  at  vomiting  seemed  the  prelude  of 


RESULTS. 


251 


instrumentally  by  the  long  or  short  forceps.i  In  all  these  varieties 
of  operative  practice,  the  previous  siiperinduction  of  anaesthesia  has 
appeared  to  me  to  be  of  the  greatest  and  most  undoubted  benefit. 
For,  besides  freeing  the  mother  from  the  additional  corporeal  suffer- 
ing and  additional  mental  anxiety  attendant  upon  operative  delivery, 
the  state  of  anassthesia  enables  the  practitioner  to  apply  any  opera- 
tive interference  that  may  be  necessary  with  more  ease  and  facility 
to  himself,  and  consequently  also  with  more  safety  and  success  to 
his  patient.  When  the  state  of  anaesthesia  is  rendered  adequately 
deep,  it  renders  the  patient  quiet  and  unresisting  during  the 
required  operative  procedures  ; it  prevents,  on  her  part,  those  sudden 
shrinkings  and  changes  of  position  which  the  boldest  and  firmest 
woman  cannot  sometimes  abstain  from  when  her  mind  and  body 
have  been  worn  out,  as  happens  in  most  operative  cases,  by  a pre- 
vious long  and  protracted  endurance  of  exhausting  but  still  ineffec- 
tual labour  pains ; — the  introduction  of  the  hand  into  the  maternal 
passages,  or  of  the  hand  to  guide  our  instruments,  is  greatly  facili- 
tated both  by  the  passiveness  and  apathetic  state  of  the  mother,  and 
by  that  relaxation  of  the  passages  which  deep  anaesthesia  almost 
always  induces ; and,  lastly,  this  state  of  relaxation  and  dilatability 
renders  the  process  of  the  artificial  extraction  of  the  infant  through 
these  passages  alike  more  easy  for  the  practitioner,  less  dangerous 
for  the  child,  and  more  safe  for  the  structures  of  the  mother. 

immediate  dissolution.  “Before  tying,”  says  he,  “the  arteries,  I waited  to  as- 
certain whether  the  condition  of  the  patient  depended  upon  syncope  or  death. 
My  colleague.  Dr.  Duncan,  by  causing  alternate  pressure  and  relaxation  of  the 
chest,  effected  artificial  respiration  for  some  time  without  any  sign  of  returning 
life  ; but  by  and  b}"  the  actions  of  the  system  were  gradually  restored,  and  main- 
tained through  the  use  of  stimulants.” — See  Monthly  Journal  of  Medical  Science^ 
vol.  1847-48,  p.  76.  Such  dangerous  symptoms,  coming  on  in  an  anaesthised 
patient,  might  have  been  mistaken  for  the  effects  of  the  anaesthesia. 

Some  time  ago,  before  either  ether  or  chloroform  was  used  in  surgery.  Dr.  John 
Argyll  Robertson  was  called,  a few  miles  out  of  Edinburgh,  to  perform  the  opera- 
tion for  strangulated  hernia.  After  having  sliaved  the  groin  for  this  purpose,  his 
patient  complained  of  sickness  and  faintness,  and  died  before  any  incisions  were 
made. 

Last  year.  Dr.  Girdwood  of  Falkirk  came  to  Edinburgh  to  see  the  practice  of 
anaesthesia,  in  order  to  be  able  to  apply  it  in  a case  of  amputation.  The  day  for 
the  operation  and  anaesthesia  was  fixed  ; but,  some  hours  previously,  sudden 
apoplexy  came  on,  and  the  patient  died.  See  also  p.  152.  [Ed.] 

^ In  one  case  of  placenta  praevia  to  which  I was  called,  the  mother  had  lost 
much  blood,  and  her  lips  were  pale,  and  her  pulse  very  weak.  On  administering 
chloroform,  the  circulation  and  pulse  rallied  ; I separated  the  placenta,  no  bleed- 
ing recurred  ; and  several  hours  afterwards  the  child  was  born.  The  mother  made 
an  excellent  recovery. 


252 


APPLICATIONS  IN  MIDWIFERY. 


Besides,  in  midwifery,  as  in  surgery,  the  utility  of  anaesthesia  before 
operating,  is  not,  I believe,  limited  to  the  mere  annulment  and 
abrogation  of  conscious  pain  on  the  part  of  the  patient,  and  the 
rendering  of  the  operation  itself  more  easy  to  the  practitioner,  but 
it  adds  to  the  safety  of  our  instrumental  or  artificial  interference. 
For,  in  modifying  and  obliterating  the  condition  of  conscious  pain, 
the  “ nervous  shock  ” otherwise  liable  to  be  produced  by  such  pain, 
particularly  wherever  it  is  extreme  in  degree  or  duration,  or  intensely 
waited  for  and  endured,  is  saved  to  the  already  tried  and  shattered 
constitution  of  the  mother ; and  thus  an  escape  is  so  far  gained  from 
those  states  of  immediate  vascular  and  nervous  depression,  and  of 
subsequent  febrile  and  inflammatory  reactions,  that  are  always  apt 
to  follow  more  directly  or  indirectly  in  its  train. 


PART  YI. 


LOCAL  ANESTHESIA. 


CHAPTER  I. 

PRELIMINARY  NOTICE  REGARDING  ARTIFICIAL  LOCAL  AN.ESTHESIA. 


Edinhurgli,  July  1848. 

I HAVE  already  attempted  to  show’  that  the  artificial  production  of 
a state  of  general  anaesthesia  before  the  performance  of  surgical 
operations  is  not  altogether  an  idea  of  modern  times. 

The  ancients,  also,  seem  to  have  entertained  the  idea  of  the 
possibility  of  producing  a state  of  local  and  limited  anaesthesia  in 
any  part  to  be  operated  upon.  Dioscorides,  -who,  as  Ave  have  seen, 
repeatedly  mentions  the  production  of  yeneral  anaesthesia  by  man- 
dragore,  states  it  as  a matter  of  report  that  local  anaesthesia  in  a 
part  Avas  capable  of  being  produced  by  the  Memphian  stone.  “ The 
Memphian  stone,”  says  he,  “ is  found  in  Egypt  near  ]\Iempliis,  of  the 
size  of  a calculus,  fatty,  and  of  different  colours.  They  say  that 
this,  when  bruised,  and  spread  over  parts  that  are  to  be  cut  or 
cauterised,  produces  in  them  a dangerless  anaesthesia.” 

Whilst  Ave  may  entirely  doubt  whether  local  anaesthesia  Avas 
capable  of  being  produced  by  such  an  apocryphal  application  as  the 
above,  the  passage  is  curious,  as  evidence  that  the  idea  of  obtunding 
a single  part  of  the  body  against  the  pain  of  an  operation,  Avas  not 
unknown  or  unthought  of  in  former  times.  -Nay,  many  old  autho- 
rities believed  that  against  the  fire-ordeal,  any  part  of  the  body 
could  be  so  protected  and  defended  by  previous  applications,  that 
the  human  hand,  for  instance,  should  not  feel  the  contact  of  red-hot 
iron.  The  Avritings  of  Eusebe  Salverte,  and  of  Beckmann,  contain 
ample  notices  on  this  disputed  question.  UpAvards  of  half-a-century 

^ See  ante.  Part  I.  Chap.  L 


254 


LOCAL  ANESTHESIA. 


ago,  our  countryman,  Dr.  Moore,  ingeniously  proposed  to  effect  a 
colal  antestliesia  of  any  limb  that  was  to  be  operated  upon  by  pre- 
viously compressing  with  tourniquets  and  pads  the  nervous  trunks 
going  to  that  limb ; and  he  has  left  us  an  interesting  account^  of  a 
case  of  amputation  at  St.  George’s  Hospital,  in  which  this  plan  was 
tried,  apparently  with  partial  success,  by  John  Hunter. 

^ See  Ills  Method  of  Preventing  or  Diminishing  Pain  in  several  Operations  of 
Surgery,  London,  1784. — “I  communicated,”  says  ]\Ir.  Moore,  p.  30,  “the  ex- 
periments I had  made,  and  all  my  ideas  on  the  subject,  to  Mr.  Hunter,  who  Avas 
so  obliging  as  immediately  to  offer  me  an  opportunity  of  trying  the  effect  of  my 
compressor,  at  St.  George’s  Hospital,  on  a man  whose  leg  he  was  to  take  off  below 
the  knee,  within  a few  days.  I went  to  the  Hospital  the  day  before  the  operation 
to  try  the  instrument.  The  patient  had  lost  all  his  toes,  and  had  a large  ulcer  on 
nis  foot.  This  was  so  much  inflamed,  and  so  irritable,  that  dressing  it  in  the 
gentlest  manner  gave  him  the  most  acute  pain.  I applied  the  instrument ; after 
the  compression  had  been  continued  for  about  half-an-hour  his  limb  became  so 
insensible  that  rubbing  pretty  smartly  wdth  the  finger  upon  the  ulcer  gave  no  pain. 
Next  morning,  the  patient  being  carried  into  the  operation  room,  I began  the 
compression  of  the  nerves  at  a quarter  before  eleven  o’clock.  The  numbness  of 
the  limbs  followed  at  the  usual  time.  At  a quarter  before  twelve  I gave  him  one 
grain  of  opium  to  diminish  the  smarting  of  the  wound  after  the  operation,  when 
the  compression  should  be  taken  off.  A few  minutes  after  twelve  the  tourniquet 
was  applied,  and  the  amputation  performed  by  Mr.  Hunter,  at  the  usual  place 
below  the  knee. 

“ At  the  circular  incision  through  the  skin,  the  patient  did  not  cry  out,  change 
a muscle  of  his  face,  or  show  any  symptoms  of  pain.  At  the  subsequent  parts  of 
the  operation,  particularly  during  the  sawing  of  the  bones,  he  showed  marks  of 
uneasiness  in  his  countenance,  but  did  not  cry  out.  As  it  was  thought  neces- 
sary to  take  up  no  less  than  five  arteries,  the  operation  lasted  a longer  time  than 
is  usual,  and  towards  the  end  he  grew  faintish,  and  desired  to  have  some  water, 
and  afterwards  asked  if  they  were  nearly  done.  When  the  operation  seemed  to  be 
over,  and  the  bleeding  stopt,  the  tourniquet  was  relaxed,  and  I also  removed  the 
compressor  ; but  a small  vessel  bleeding  unexpectedly,  it  was  thought  necessary 
to  tie  it  also.  Here  the  patient  showed  very  strong  marks  of  pain,  and  afterwards 
declared  that  tying  this  last  vessel  gave  him  much  more  pain  than  all  the  others, 
although  the  great  nerves  had  been  included  in  the  ligatures.  When  he  was  put 
to  bed  the  wound  smarted,  as  is  usual  after  amputations.  The  compressor  being 
now  entirely  removed,  this  was  to  be  expected.  But  sometime  after,  being  ques- 
tioned concerning  the  pain  he  had  suffered  during  the  operation,  he  declared  that 
he  had  felt  hardly  any,  except  (as  he  himself  expressed  it),  at  the  rasping  of  the 
bones,  which,  he  added,  had  shaken  his  whole  limb.  This  seems  a little  extra- 
ordinary, as  sawing  the  bones  is  usually  the  least  painful  part  of  amputations.” 
* * * “ This  trial  had  all  the  success  I expected  ; there  was  evidently  a most 

remarkable  diminution  of  pain,  particularly  during’the  first  incisions  through  the 
skin  and  muscles,  Avhich  are  generally  by  far  the  most  severe  parts  of  the  opera- 
tion, and  I am  convinced  that  what  pain  the  patient  felt  was  chiefly  owing  to 
some  small  branches  of  the  lumbar  nerves  which  extend  below  the  knee,  and  were 
not  compressed.”  Perhaps  some  of  our  modern  surgeons  will  not  consider  inclu- 
sion of  the  great  nerves  in  the  arterial  ligatures  as  any  compliment  to  Mr.  Hunter’s 
surgery. 


PRELIMINARY  RESULTS. 


255 


The  possible  production  of  local  anoestliesia  by  this  or  other 
means  is  certainly  an  object  well  worthy  of  study  and  attainment. 
Surgeons  everywhere  seem  to  be  more  and  more  acknowledging  the 
facility,  coHninty,  and  safety,  vHth  which  the  state  of  general  anaes- 
thesia can  be  produced  at  will  before  operating,  and  the  moral  and 
professional  necessity  of  saving  their  patients  from  all  unrequisite 
pain.  But  if  we  could  by  any  means  induce  a local  anaesthesia 
without  that  temporary  absence  of  consciousness  which  is  found  in 
the  state  of  general  anaesthesia,  many  would  regard  it  as  a still 
greater  improvement  in  this  branch  of  practice.  If  a man,  for 
instance,  could  have  his  hand  so  obtunded  that  he  could  see  and  yet 
not  feel  the  performance  of  amputation  upon  his  own  fingers,  the 
practice  of  anaesthesia  in  surgery  would,  in  all  likelihood,  advance 
and  progress  still  more  rapidl}^  than  ever  it  has  done. 

In  the  following  remarks  it  is  my  object  to  state  the  results  of 
a number  of  experiments  which  I have  performed — 15^,  Upon  the 
lower  animals ; and  2d,  Upon  man,  with  a view  to  the  possibility 
of  the  production  of  such  a state  of  local  anaesthesia,  by  the  local 
application  of  chloroform  or  other  anaesthetic  agents,  to  individua 
parts  of  the  body. 


256 


LOCAL  ANESTHESIA 


CHAPTER  II. 

ON  THE  PRODUCTION  OF  LOCAL  ANESTHESIA  IN  THE 
LOWER  ANIMALS. 

Edinburgh,  July  1848. 

At  a meeting  of  the  Medico-Chirurgical  Society  of  Edinburgh  held 
on  the  17th  May  1848,  I took  occasion  to  state  that  I had  success- 
fully chloroformed  several  of  the  lower  animals — annelida,  Crustacea, 
fishes,  etc.  : that  in  some,  especially  in  the  common  earthworm 
{Lumhricus  terrestris),  I had  been  able  to  produce  local  anaesthesia 
by  applying  the  chloroform  vapour  locally  ; and  had  thus,  at  will, 
rendered  anaesthetic  individual  parts  and  portions  of  the  worm,  as 
the  head  merely,  or  the  tail  merely,  or  the  middle  part  of  the  worm 
merely,  the  head  and  tail  remaining  unaffected.^  At  one  of  the 
February  meetings,  1 stated  that  in  the  human  subject  local 
anaesthesia  of  a portion  of  the  gums  could  be  produced  by  rubbing 
the  part  with  hydrocyanic  acid.  After  the  date  of  the  above  meet- 
ing I was  led  to  make  some  additional  experiments  upon  the  pos- 
sible production  of  local  anaesthesia  in  man,  which  I here  intend  to 
detail  at  greater  length. 

Nothing  could  be  more  curious  or  satisfactory  than  the  experi- 
ments alluded  to  on  the  production  of  local  anaesthesia  by  the  local 
application  of  chloroform  vapour  to  different  parts  of  the  body  of 
the  earthworm.  The  resulting  degree  of  local  anaesthesia  in  the 
part  exposed  is  generally,  in  the  course  of  two  or  three  minutes, 
most  complete  as  regards  both  sensation  and  motion ; in  fiict,  after 
being  sufficiently  exposed,  the  chloroformed  portion  of  the  animal  is 

1 Dr.  Simpson  stated  that  he  liad  successfully  chloroformed  some  of  the  lower 
animals — fishes,  Crustacea,  annelida,  etc.,  and  last  year  he  had  etherised  the  sen- 
sitive plant  {Mimosa  imdica).  He  had  found,  for  example,  the  common  earth- 
worm {Lumhricus  terrestris)  very  susceptible  of  the  action  of  the  vaj)Our  of 
chloroform.  Dr.  Simpson  further  stated  that  he  had  found  he  couhl,  with 
chloroform  vapour,  render  antesthetic  individual  parts  of  the  worm  merely,  the 
head  and  tail  remaining  unaffected.  He  could  produce  this  local  aufcsthesia  in 
tlie  worm  by  applying  the  vapour  locally. — See  Monthly  Journal  for  July  1848, 
p.  48.  [Ed.] 


IN  LOWER  ANIMALS. 


257 


quite  flat  and  flaccid,  does  not  move  under  any  irritation,  and  can 
be  doubled  and  twisted  upon  itself  like  a piece  of  loose  wetted 
cord.  If  the  part  paralysed  by  the  chloroform  is  small,  it  will  be 
dragged  along  by  the  movements  of  the  other  unaffected  portions  of 
the  worm.  Generally,  in  the  course  of  a few  minutes,  it  gradually 
regains  its  powers  of  motion,  and  its  irritability  and  contraction 
under  stimuli.^ 

The  easiest  method  of  performing  this  experiment,  is  to  place  a 
small  quantity  of  chloroform  in  the  bottom  of  a tumbler,  paste  over 
the  mouth  of  it  a covering  of  paper,  and  make  an  aperture  in  this 
covering  sufficient  only  to  admit  the  portion  of  the  animal  that  is  to 
be  chloroformed.  When  held  in  this  position,  the  part  of  the 
animal  below  the  paper  and  exposed  to  the  vapour  of  chloroform, 
is  generally  thrown  into  violent  movements  for  a minute  or  two 
before  the  state  of  anaesthesia  supervenes.  I have  repeated  the 
same  experiments  with  the  vapours  of  sulphuric  ether  and  of 
bisulphuret  of  carbon. 

I have  tried  the  same  experiment  with  the  same  results  upon 
the  medicinal  leech. 

The  results  were,  if  possible,  still  more  marked  in  another  of  the 
Articulata  that  was  submitted  to  experiment.  A small  myriapode 
or  centipede  {Julus  sahidosust)  was  rendered  completely  anaesthetic 
and  motionless  in  the  posterior  segments  of  its  body,  by  exposing 
that  part  alone  for  a few  minutes  to  the  vapour  of  chloroform. 
The  five  or  six  last  rings  of  the  centipede,  with  the  suspended  and 
motionless  feet  attached  to  them,  were,  for  a short  time  afterwards, 
dragged  about  in  a kind  of  paraplegic  state,  by  the  brisk  and  lively 
movements  of  the  anterior  and  unaffected  portion  of  the  animal. 
The  animal  soon  and  completely  recovered,  each  segment  with  its 
corresponding  feet  regaining  its  power  of  motion ; and  this  in 
regular  order  from  before  backwards. 

In  other  centipedes  experimented  upon,  a small  quantity  of 
fluid  chloroform  was  applied  by  a slight  brush  to  the  head,  or  to 
two  or  three  of  the  middle  rings  of  the  animal,  or  to  the  tail,  and 
always  with  the  eftect  of  anaesthetising  and  paralysing  the  part  or 
parts  only  with  which  the  .chloroform  came  in  contact.  Sometimes, 

^ These  experiments  become  the  more  interesting  in  a physiological  and 
toxicological  point  of  view,  when  we  recollect  that  in  the  Articnlata  the  vascular 
system  is  general  and  distributed  longitudinally,  while  both  the  nervous  and 
respiratory  system  of  this  class  of  animals  is,  in  a great  measure,  segmentary  and 
transverse,  like  the  action  of  the  antesthetic. 


258 


LOCAL  ANAESTHESIA 


wlieii  the  head  and  anterior  rings  were  alone  touched,  the  animal, 
after  vainly  trying  to  push  its  motionless  head  forwards,  suddenly 
reversed  the  movements  of  all  its  limbs  for  a time,  and  dragged  the 
XJaralysed  head  behind  it.  All  of  the  centipedes  experimented  on 
recovered  in  a very  short  time  from  the  effects  of  the  chloroform. 

By  immersing  the  tail  of  the  water-newt  in  chloroform  vapour, 
the  sensibility  and  motions  of  that  part  were  rapidly  destroyed,  and 
returned  in  a few  minutes  afterwards.  By  a longer  degree  of 
immersion  of  the  tail  alone,  the  whole  animal  became  anaesthetic ; 
and  in  several  experiments  it  was  found  possible,  but  difficult,  to 
give  the  animal  in  this  way  a fatal  dose  of  the  vapour. 

The  hind-leg  of  the  frog  becomes  anaesthetic  when  exposed  for 
four  or  five  minutes  to  the  vapour  of  chloroform.  Immediately  after, 
it  drags  the  limb  in  progressing,  and  bears,  apparently  without 
feeling,  pricking  and  irritation  of  it ; but  a galvanic  current  passed 
through  it  excites  both  sensacion  and  motion.  In  one  case,  the 
motory  power  of  the  limb  was  not  restored  at  the  end  of  the  third 
day.  No  effect  appeared  to  result  from  keeping  the  hind-leg  of  this 
animal  immersed  in  strong  tincture  of  Indian  hemp. 

One  hind-leg  of  a healthy,  active  rabbit,  was  confined  in  a large 
bladder  containing  the  vapour  of  chloroform.  At  the  end  of  an 
hour  the  common  sensibility  of  the  limb  to  pinching  and  squeezing 
was  much  impaired ; but  a current  of  galvanism  passed  through  it 
l)roduced  crying  and  signs  of  pain.  The  power  of  moving  the  limb 
seemed  unimpaired. 

The  hind-leg  of  a guinea-pig,  similarly  treated,  exhibited  the 
same  phenomena  at  the  end  of  an  hour ; but  the  anaesthesia  was 
more  complete.  The  skin  of  the  leg  was  red  and  congested. 

The  posterior  extremities  and  pelvis  of  a strong  guinea-pig  were 
enclosed  in  a bag  containing  the  vapour  of  chloroform.  At  the  end 
of  an  hour,  no  signs  of  pain  could  be  extracted  by  pinching  and 
squeezing  either  limb  ; and  a current  of  electricity  passed  through 
a hind-leg  evidently  caused  much  less  pain  than  when  the  same 
current  was  passed  through  a fore-leg.  The  whole  hinder  parts 
were  very  red  and  congested.  The  animal  was  also  in  some  degree 
paraplegic,  and  dragged  itself  along  by  strong  efforts  with  its  an- 
terior limbs. 

In  an  interesting  communication  addressed,  on  the  7th  of  June 
1848,  to  the  Yorkshire  Branch  of  the  Provincial  Association,  and 
published  in  the  number  of  the  Provincial  Journal  for  June  28,  Mr. 
Nunn eley  of  Leeds  has  stated  that  he  has  produced  complete  para- 


IN  LOWER  ANIMALS. 


259 


lysis  of  the  individual  limbs  of  frogs  and  toads,  by  immersion  or 
exposure  of  them  for  a few  minutes  to  the  vapour  of  chloroform  ; 
that  by  a similar  but  longer  immersion  he  had  rendered  the  leg  of 
the  rabbit  sufficiently  ansesthetic  to  bear  mutilation  without  pain  ; 
that  he  had  immersed  his  own  finger  in  ansesthetic  fluids  for  about 
half-an-hour  or  an  hour,  and  at  the  end  of  that  time  it  was  nearly 
powerless  and  insensible,  nor  was  it  entirely  recovered  for  forty- 
eight  hours  ; that  in  operating  on  the  human  eye  he  had  rendered 
the  organ  ansesthetic  by  previously  exposing,  it  for  about  twenty 
minutes  to  the  vapour  of  chloroform ; and  that,  in  his  opinion,  the 
action  of  all,  or  of  most  ansesthetic  agents  might  be  produced  locally 
by  their  local  application,  the  sensorium  being  unaffected,  conscious- 
ness retained,  and  the  limbs  not  subjected  to  their  influence  being 
unaffected.  This  naturally  leads  us  to  the  consideration  of — 


260 


LOCAL  ANAESTHESIA 


CHAPTER  III. 

THE  PRODUCTION  OF  LOCAL  ANAESTHESIA  IN  THE 
HUMAN  SUBJECT. 

Edinburgh,  July  1848. 

Early  in  February  1848,  I was  led  to  make  experiments  relative 
to  the  artificial  production  of  load  ancesthesia  in  a portion  of  the 
human  gums  hy  friction  with  hydrocj^anic  acid,  in  consequence  of 
being  assured,  on  what  I believed  to  be  satisfactory  evidence,  that  a 
dentist  at  Limoges,  in  France,  M.  Pernot,  had  the  secret  of  extract- 
ing teeth  with  little  or  no  pain,  in  consequence  of  previously  apply- 
ing some  obtunding  agent  to  the  gums.  I tried  at  the  time  a great 
variety  of  substances,  in  order  to  obtain  this  local  anaesthesia,  such 
as  various  ethers,  bisulphuret  of  carbon,  benzin,  aconite,  etc.  Among 
all  the  agents  employed  the  effect  of  prussic  acid  was  by  far  the 
most  decided  and  complete  ; any  part  of  the  gum  strongly  rubbed 
by  it,  speedily  became  benumbed  and  insensible ; but  the  resulting 
degree  of  an£esthesia  was  by  no  means  sufficient  for  the  purpose 
required.  The  results  of  these  experiments  were  stated  orally  to 
the  Edinburgh  Medico-Chirurgical  Society,  at  their  meeting  on  the 
16th  February  1848. 

Before  that  date  I had  met  with  one  instance  in  which  local 
anaesthesia  of  the  human  hand  had  been  produced  in  a young  lady, 
in  consequence  of  her  accidentally  holding  in  it  for  a considerable 
time  a scent-bottle  containing  some  chloroform.  I tried  at  various 
times  to  reproduce  a similar  result  in  myself  and  in  others,  by 
keeping  my  hand  wrapped  in  a napkin  soaked  in  chloroform  and 
other  anaesthetic  agents,  but  with  little,  or  indeed  no  decided 
success,  until  I used  the  vapour  of  chloroform  raised  by  heat,  the 
hand  for  the  purpose  having  been  immersed  in  a deep  jar,  into 
which  a small  quantity  of  chloroform  was  poured — the  jar  tempo- 
rarily placed  in  a basin  of  water  of  the  temperature  of  ISO*^  or  up- 
wards, and  the  wrist  or  forearm  being  surrounded  by  handkerchiefs, 
so  as  to  prevent  the  escape  of  the  vapour. 


IN  MAN. 


261 


A numler  of  circumstances  influence,  liowever,  tlie  effect  and 
the  degree  of  the  state  of  local  ancesthesia ; and  as  I have  made  a 
considerable  variety  of  experiments,  both  upon  myself  and  upon 
others,  in  order  to  ascertain  these  points,  I will  shortly  state  the 
results.  Let  me  premise,  that  in  the  experiments  upon  which  the 
following  results  are  founded,  the  hands  of  the  same  individual 
were  generally  held  simultaneously  in  two  different  jars,  differently 
arranged  in  regard  to  material  or  otherwise,  in  order  to  make  two 
different  and  comparative  experiments  at  the  same  time ; and  the 
relative  degree  of  anaesthesia  in  each  hand  was  ascertained,  during 
the  experiment,  by  pinching  the  fingers  with  the  thumb-nail,  without 
removing  the  hand  from  the  jar.  After  they  were  removed,  these 
and  other  more  severe  measures  were  used  with  the  same  view,  as 
tests  of  the  degree  of  anaesthesia.  Most  of  the  experiments  referred 
to  were  repeated  and  tried  upon  several  different  individuals.  The 
general  results  were  the  following : — 

1.  When  the  hand  is  exposed  to  an  anaesthetic  vapour,  it 
betimes  presents  the  sensations  of  a limb  benumbed,  by  compression 
of  its  larger  nervous  trunks — the  sensations,  in  fact,  of  partial  or 
commencing  paralysis.  Usually,  after  a short  time,  a glowing  or 
burning  feeling  is  perceived  in  the  parts  most  exposed,  and 
gradually  there  supervenes  a sensation  of  thrilling  and  tingling  (like 
a limb  asleep),  which  deepens  more  and  more.  The  skin  turns  red, 
and  the  hand  at  last  becomes  stiff  and  clumsy,  and  feels  as  if  en- 
larged, and  painful  impressions,  as  pricking,  pinching,  etc.,  are  felt 
less  and  less  than  in  the  other  unexposed  hand.  After  the  hand 
experimented  upon  is  removed  from  the  vapour,  it  is  generally  half- 
an-hour  or  more  before  its  usual  normal  feelings  are  quite  restored. 
The  nerves  of  motion  are  usually  apparently  as  much  affected  as  the 
nerves  of  sensation. 

2.  When  the  jar  containing  the  chloroform,  or  other  anaesthetic 
fluid  experimented  upon,  was  immersed  in  ^varm  water,  so  as  to 
raise  the  vapour  of  the  fluid  more  fully  and  quickly,  the  resulting 
anaesthetic  effect  was  always  greatly  increased,  both  in  rapidity  and 
intensity. 

3.  The  vapour  of  chloroform  proved  stronger  than  any  other 
that  was  tried.  AVhen  one  hand,  for  instance,  was  immersed  in  a 
jar  containing  the  vapour  of  sulphuric  ether,  and  the  other  in  a jar 
containing  the  vapour  of  chloroform,  both  jars  containing  similar 
quantities,  and  being  subjected  to  the  same  degree  of  heat,  the  hand 
in  the  chloroform  jar  was  both  more  speedily  and  more  deeply 


262 


LOCAL  ANAESTHESIA 


affected  than  the  other.  In  addition  to  the  vapour  of  chloroform 
and  ether,  I have  tried  comparative  experiments  with  the  vapours 
of  aldehyde,  bisulphuret  of  carbon,  iodide  of  methyle,^  etc.  The 
aldehyde  had  little  or  no  effect  of  any  kind.  The  iodide  of  methyle 
produced  a very  severe  burning  sensation,  and  left  the  hand  in- 
tensely red  and  erythematous  for  a day  or  two  afterwards,  but  with 
no  marked  ansesthetic  influence.  Among  several  of  us  that  tried 
the  vapour  of  bisulphuret  of  carbon,  only  one  bore  it  for  any  length 
of  time  (about  an  hour),  and  in  him  it  did  not  render  the  hand 
anaesthetic  in  any  very  appreciable  degree  ; in  myself  and  others  the 
sensation  of  heat  and  burning  became  so  utterly  intolerable,  as  to 
force  us  to  withdraw  the  hand  in  two  or  three  minutes.  Immersion 
of  the  hand  for  half-an-hour  in  Dr.  Fleming’s  very  powerful  tincture 
of  aconite,^  or  in  a strong  tincture  of  opium,  or  of  Indian  hemp,  or 
in  a strong  solution  of  belladonna,  produced  no  appreciable 
anaesthetic  effect. 

4.  The  hand,  when  plunged  in  liquid  chloroform,  is  usually 
somewhat  more  deeply  apathised  than  the  other  hand  simultaneously 
held  in  the  vapour  of  chloroform.  This  was  the  more  general  result 
with  those  who  tried  the  experiment ; but  in  some  the  chloroform 
vapour  was  as  anaesthetic,  or  more  so,  than  the  liquid.  Few  persons 
can  keep  the  hand  for  any  adequate  length  of  time  in  liquid  chloro- 
form ; the  sensation  of  burning  becomes  so  intense  and  insufferable 
as  to  force  them  to  withdraw  it  in  a very  few  minutes.  On  one 
occasion  I held  my  hand  for  upwards  of  an  hour  in  liquid  chloroform 
without  the  part  being  more  deeply  apathised  than  it  would  have 
been  by  exposure  to  the  vapour.  One  of  my  pupils,  Mr.  Adams, 

1 Two  or  three  months  ago  I began  a series  of  experiments  with  the  intention 
of  testing  the  anesthetic  or  other  therapeutic  effects  of  the  various  respirable  com- 
pounds of  amethyle,  acetyle,  etc.  I was  prevented  from  proceeding  far  in  the 
inquiry,  in  consequence  of  the  effects  following  the  inhalation  of  the  compound 
mentioned  in  the  text,  viz.  iodide  of  methyle.  I found  it  very  powerfully  anjes- 
thetic,  hut  dangerously  so.  After  inhaling  a very  small  quantity  of  it  for  two  or 
three  minutes,  I remained  for  some  seconds  without  feeling  much  effect ; hut 
objects  immediately  began  to  multiply  before  my  eyes,  and  I fell  down  in  a state 
of  insensibility,  which  continued  for  upwards  of  an  hour.  I did  not  completely 
recover  from  the  effects  of  it  for  some  days. 

2 Some  other  forms  or  preparations  of  this  and  the  other  substances  may  pos- 
sibly produce  different  results,  as  we  know  that  aeonite,  when  chewed,  causes  a 
numbness  and  tingling  in  the  lips  and  tongue,  lasting  for  some  hours.  See 
Christison  on  Poisons,  p.  2.  In  making  this  experiment  with  aconite,  it  ap- 
peared to  me  that  the  sensibility  of  the  tongue,  etc.,  Avas  not  decreased  to  pinch- 
ing, etc.,  when  the  part  was  tingling  from  the  effects  of  the  chewing  of  the 
aconite. 


IN  MAN. 


263 


perseveringly  retained  his  hand  in  the  liquid  chloroform  for  upwards 
of  two  hours : no  great  or  very  marked  degree  of  local  ansesthesia 
resulted.  In  these  cases,  in  which  the  hand  was  long  steeped  in 
liquid  chloroform,  the  sensations  of  burning  returned  severely,  from 
time  to  time,  as  if  in  waves,  during  the  experiment ; and  on  re- 
moving it  from  the  jar,  the  feelings  of  heat  were  temporarily  ag- 
gravated. The  normal  sensibility  of  the  parts  speedily  returned, 
and  was  completely  restored  within  an  hour  or  two  in  all,  but  the 
skin  sometimes  remained  red  and  injected  for  a longer  period ; 
occasionally  for  several  hours. 

5.  The  anaesthetic  effect  of  chloroform,  etc.,  is  increased,  both  in 
rapidity  and  in  degree,  by  immersing  the  hand,  with  the  cuticle 
softened  and  moist.  When  one  hand,  for  instance,  is  immersed 
without  any  preparation,  and  the  other  is  prepared  by  being  bathed 
and  fomented  for  ten  or  twenty  minutes  previously,  the  latter  almost 
immediately  begins  to  tingle  under  exposure  to  the  vapour,  the  dry 
hand  not  for  some  minutes.  The  degree  of  anaesthesia  is  also  ulti- 
mately deeper  in  the  moistened  hand. 

6.  The  degree  of  delicacy  of  skin  in  the  person  or  part  exposed 
to  the  anaesthetic  vapour  influences  the  result.  In  females  I have 
seen  the  degree  of  the  local  anaesthesia  of  the  hand  that  was  pro- 
duced, much  greater  and  deeper  than  I could  ever  render  it  in  the 
male  subject.  In  applying  the  vapour  of  chloroform  in  small 
cupping  glasses,  etc.,  to  different  parts  of  the  body,  as  the  insides  of 
the  arms,  etc.,  the  resulting  degree  of  local  anaesthesia  seemed,  in  a 
great  measure,  regulated  by  the  tenuity  of  the  skin  of  the  part  ex- 
perimented upon.  The  skin  of  the  axilla  seems  too  tender  to  allow 
of  the  vapour  being  applied  for  a length  of  time  sufficient  to  pro- 
duce anaesthesia.  One  of  my  students,  who  kept  both  his  lower 
extremities  enveloped  in  strong  chloroform  vapour  for  three  con- 
tinuous hours,  felt  no  appreciable  local  anaesthetic  effect  from  it. 

When  strong  chloroform  vapour  is  locally  applied  to  mucous 
surfaces,  the  attendant  sensations  of  heat  and  smarting  are  too 
severe  to  allow  of  its  sufficient  continuance ; at  least,  this  is  the 
result  that  I have  obtained  in  applying  it  with  small  glasses  to  the 
inside  of  the  lips,  the  tongue,  and  eye.  Mr.  .Nunneley  states,  as 
we  have  already  mentioned,  that  before  operating  on  a difficult  case 
of  artificial  pupil,  he  had  applied  for  twenty  minutes  a small 
quantity  of  the  vapour  of  chloroform  to  the  eye,  by  means  of  a 
small  jar,  which  accurately  filled  the  orbit,  with  the  effect  of  ren- 
dering the  parts  nearly  insensible.  Dr.  Duncan  and  myself  have 
73 


264 


LOCAL  ANESTHESIA 


repeatedly  tried  this  experiment  upon  ourselves ; but  in  none  of 
the  trials  which  we  made,  with  the  eye  either  shut  or  open,  could 
we  endure  the  burning  action  of  the  vapour  upon  the  part  above 
two  or  three  minutes,  and  with  no  other  result  except  always  ren- 
dering the  eye  experimented  upon  red  and  injected,  and  suffused 
with  tearsd 

7.  The  degree  of  ansesthesia  produced  in  the  hand  by  exposure 
of  it  to  the  strong  vapour  of  chloroform,  does  not,  in  general,  per- 
ceptibly increase  after  fifteen  or  twenty  minutes.  The  same  sensa- 
tions continue  if  the  hand  is  still  retained  in  the  jar ; but  an  increased 
length  of  exposure  does  not,  after  a time,  produce  a corresponding 
increased  degree  of  local  insensibility. 

But,  finally  and  specially,  I would  observe  that  the  degree  of 
local  anaesthesia  produced  in  the  human  hand  or  skin,  by  exposing 
it  to  the  local  action  of  the  vapour  of  chloroform,  has  never,  in  my 
experiments,  been  by  any  means  so  deep  and  complete  in  its  cha- 
racter as  to  give  the  chance  of  annulling  the  pain  of  any  severe  opera- 
tion, such  as  the  deep  incision  or  amputation  of  a finger.  As 
compared  with  the  other  non-exposed  hand,  the  chloroformed  hand 
is  generally  rendered,  to  a marked  amount,  less  sensitive ; but  the 
insensibility  is  never,  I fear,  so  entire  and  perfect  as  will  save  the 
patient  from  the  pain  of  the  surgeon’s  knife.  In  short,  I altogether 
doubt,  whether,  in  the  human  subject,  we  shall  ever  be  able  to 
reduce  the  knowledge  of  this  possible  production  of  partial  local 
anaesthesia  to  any  practical  purpose.  It  is  principally  interesting 
in  a toxicological  and  physiological  point  of  view,  and  in  relation 
to  the  doctrine  of  the  mode  of  action  of  anaesthetic  agents.^  Its 

^ I have  tried  the  application  of  various  anaesthetic  gases  and  vapours  to  the 
vagina,  in  cases  of  vaginal  irritation  and  neuralgia.  The  stronger  forms  cannot 
be  borne.  I was  induced  to  try  them  in  consequence  of  the  following  curious 
statement  regarding  carbonic  acid,  published  by  Dr.  Pereira  {Materia  Mediea,  vol. 
i.  p.  155). — “A  lady  who  had  suifered  a considerable  time  from  some  uterine 
affection,  and  had  derived  no  relief  from  the  treatment  adopted,  was  advised  to 
consult  a physician  in  Italy  (Dr.  Eossi).  After  he  had  examined  the  condition  of 
the  uterus,  he  assured  her  there  was  no  organic  disease,  but  merely  a considerable 
degree  of  irritation,  for  which  he  proposed  to  apply  carbonic  acid  as  a sedative. 
This  Avas  done  by  means  of  a pipe  and  tube,  commiuiicating  with  a gasometer 
situated  in  another  room.  The  patient  obtained  immediate  relief,  and  although 
she  had  been  obliged  to  be  carried  to  the  doctor’s  house  on  account  of  the  pain 
experienced  in  walking,  she  left  it  in  perfect  ease.  On  her  return  to  England  she 
had  a relapse  of  the  cojnplaint,  and  applied  to  Dr,  Clutterbuck  to  know  whether 
she  could  have  the  same  remedy  applied  in  London,  in  order  to  save  her  the  neces- 
sity of  returning  to  Italy. 

2 The  distinction  which  exists  between  the  structure  and  functions  even  of  the 


IN  MAN. 


265 


bearings  are  more  upon  the  theory  than  upon  the  practice  of 
anaesthesia. 

These  remarks  relate  to  local  anaesthesia  as  capable  of  being 
produced  by  the  anaesthetic  agents  with  which  we  are  at  present 
acquainted.  Others  may  no  doubt  yet  be  detected,  much  more 
powerful  than  any  we  at  present  know,*  and  their  local  application 
may  enable  us  to  effect  the  local  anaesthesia  desired.  At  the  same 
time,  this  consummation,  even,  seems  doubtful ; for,  perhaps,  any 
agent  possessing  a deeper  and  more  rapid  anaesthetic  local  power, 
would  by  absorption  affect  the  system  generally,  and  it  may  be, 
dangerously,  before  complete  local  insensibility  of  a part  could  be 
effected.  Some  time  ago,  in  attempting  to  produce  local  anaesthesia 
in  my  hand,  by  exposing  it  to  the  vapour  of  hydrocyanic  acid,  ere 
the  hand  w^as  much  or  very  perceptibly  benumbed  I began  to  feel 
the  constitutional  effects  of  the  poison  ; my  respiration  became 
irregular,  and  I felt  giddy  and  faint,  when  my  assistant  removed  my 
hand  from  the  jar.  All  due  care  was  taken  to  prevent  me  breath-’ 
ing  any  of  the  vapour,  and  I sat  during  the  experiment  in  a current 
of  air.  I felt  the  benumbing  influence  of  the  acid  extending  from 
the  hand  upwards  along  the  arm  a minute  or  two  before  the  experi- 
ment was  stopped. 

In  addition  to  the  liquids  and  vapours  experimented  upon,  I 
have  tried  long  immersion  of  the  hand  in  various  gases,  as  carbonic 
acid  and  common  coal-gas  (both  of  them  powerful  general  anaes- 
thetics when  inhaled),  without  any  effect.  Cliaptal,  however,  alleges 

skin  in  the  lower  animals,  as  compared  with  the  skin  of  the  human  subject,  per- 
haps sufficiently  explains  the  differences  in  the  degree  of  local  anaesthesia  capable 
of  being  produced  by  the  local  application  of  anaesthetic  vapours  and  fluids  in  the 
one  and  in  the  other.  “ In  animals,”  says  Dr.  Jackson,  see  Amcr.  Cijclopccdin  of 
Pract.  Med.  and  Surgery,  etc.,  vol.  i.  p.  115,  “whose  skin  is  moist,  and  which 
possess  a very  delicate  cuticle,  cutaneous  absorption  is  a constant  and  important 
function.  Such  are  frogs,  salamanders,  and  similar  animals.  The  experiments  of 
Edwards  have  established  the  skin  in  them  to  be  entirely  absorbing,  and  instru- 
mental in  their  support.” 

1 Perhaps  some  special  modification  in  the  application  of  electricity,  galvanism, 
or  magnetism,  to  the  part  to  be  locally  anaesthetised,  may  be  yet  found  capable  of 
effecting  this  object.  I have  tried  several  experiments  of  the  kind,  but,  as  yet, 
without  much  success.  The  possibility  of  deep  local  anaesthesia  existing  in  dis- 
eased states  (as  in  colica  pictonum,  hysteria,  hypochondriasis,  etc.),  without  the 
general  sensibility  or  consciousness  being  affected,  is  well-  shown  in  a late  interest- 
ing essay  of  M.  Beau,  in  the  Archives  Gaiirales  de  Medccine  for  January  1848. 
He  relates  one  case  of  an  insane  patient  who  broke  his  fibula,  and  continued  to 
walk  about  without  pain  until  the  limb  became  inflamed  and  gangrenous.  It  was 
then  amputated,  and  still  without  the  patient  apparently  suffering  in  any  degree 
during  the  operation. 


266 


LOCAL  ANiESTHESIA 


that  lie  had  felt  the  limbs  plunged  in  carbonic  acid  much  benumbed; 
and  Collard  de  Martigny^  found  that,  when  the  general  surface  of 
his  body  was  immersed  in  carbonic  acid  (arrangements  being  made 
so  that  none  of  it  was  breathed),  giddiness,  ringing  in  the  ears,  and 
the  other  symptoms  produced  by  the  action  of  this  gas,  supervened 
in  eight  or  ten  minutes,  proving  that  it  was  absorbed.  Davy^  felt 
the  premonitory  exhilaration  of  nitrous  oxide  gas  by  exposing  the 
surface  of  his  body  to  it  in  the  same  way. 

Chaussier^  enclosed  the  leg  of  a dog  in  a bag  containing  sul- 
phuretted hydrogen,  and  found  that  he  could  in  this  way,  in  a few 
minutes,  induce  the  poisonous  effects  of  this  gas  ; and  similar  experi- 
ments were  repeated  by  Lebkuchner^  and  Nysten,^  and  my  friend 
Dr.  Madden,®  on  the  rabbit,  etc.,  with  similar  results.  I have  held 
my  hand  enclosed  in  a bag  filled  with  the  constantly-renewed  vapour 
of  sulphuretted  hydrogen  for  about  half-an-hour,  without  feeling  any 
local  effects. 

And  even  supposing  that  we  could,  by  any  means,  so  benumb 
the  sensibility  of  a part  to  be  operated  upon  as  to  render  it  anaes- 
thetic, I doubt  much  if  this  state  of  local  anaesthesia  would  place 
the  parts  in  a condition  at  all  favourable  for  being  subjected  to 
operation.  It  is  quite  possible,  nay  probable,  that  other  more 
powerful  agents  than  those  which  I have  experimented  upon,  may, 
by  their  local  application,  produce  a greater  and  deeper  local  anaes- 
thesia on  the  human  subject  than  I have  yet  witnessed ; but  all,  or 
almost  all,  of  those  that  I have  used,  have,  along  with  the  anaesthesia, 
led  to  such  a congested  and  injected  condition  of  the  part,  as  to  give 
every  likelihood,  both  of  a greater  tendency  to  hemorrhage  at  the 
time  of  operating,  and  of  a greater  tendency  to  inflammation  in  it 
immediately  afterwards. 

Other  and  raore  simple  agencies  than  any  which  I have  men- 
tioned are  capable  of  producing  a certain  amount  of  local  anaesthesia. 
A mere  exposure  of  the  hand,  for  instance,  to  great  changes  of  tem- 
perature, either  in  the  way  of  increase  or  diminution,  has  the  power 
of  deadening  the  sensibility  of  the  part.  I have  tried,  and  seen 

^ Archives  Gener.  de  Mid.,  vol.  xiv.  p.  209. 

2 Researches  on  Nitrous  Oxide,  1800,  p.  485. 

^ Sedillot’s  Journal  de  Mid.,  vol.  xv.  p.  25. 

^ Diss.  Inaug.  utrum  iier  vivcntiam  adhuc  animaliiim  mcmbranas  materia 
'ponderahiles  pcrmeare  queant,  p.  10,  etc. 

® Nysten.  Recherches  Physiologiques,  p.  137,  etc. 

® See  his  excellent  Experimental  Inquiry  into  the  Physiology  of  Cutar.ccus 
Ahsorp)tioii,  p.  13. 


IN  MAN. 


267 


others  try,  to  hold  the  hand,  with  a view  to  this,  immersed  in  broken 
ice,  or  dipped  in  ice-water,  and  with  the  effect  of  inducing  a degree 
of  anaesthesia  in  the  part,  as  deep,  if  not  deeper,  than  exposure  of 
the  same  part  for  a greater  length  of  time  to  the  local  action  of 
chloroform  would  have  effected.  In  his  admirable  and  classical 
Lectures  on  Inflammation,  the  late  Dr.  Thomson  remarks  (p.  617), 
that  “ the  sensibility  to  external  impressions  of  the  parts  exposed  to 
cold,  is  always  more  or  less  impaired,  and  the  diminution  in  the 
sensibility  of  the  nervous  system  seems  to  admit  of  degrees,  from 
the  slightest  perceptible  numbness  to  that  of  the  most  complete 
insensibility.”  But  he  also  correctly  adds  — “ This  diminution 
however,  of  the  sensibility  to  external  impressions,  is  not  unfre- 
quently  accompanied  with  severe  degrees  of  pain.”  In  fact,  in 
making  the  experiments  to  which  I have  above  adverted  with  the 
pounded  ice,  few  of  us  could  allow  the  hand  to  be  retained  in  it 
above  two  or  three  minutes,  in  consequence  of  the  intense  pain 
which  ensued  ; but  still  that  brief  period  produced,  as  I have  said, 
a most  distinct  and  w'ell-marked  degree  of  local  anaesthesia. 

Keei)ing  the  hand  immersed  in  water,  of  as  high  a temperature 
as  it  can  conveniently  bear,  has  also  the  same  effect  of  rendering  it, 
in  five  or  ten  minutes,  partially  anaesthetic  and  benumbed,  as  com- 
pared with  the  other  unexposed  hand ; and  this  without  the  pain 
and  suffering  connected  with  the  other  extreme  of  temperature. 

It  is  not  my  object  here  to  inquire  in  what  relative  diseased  or 
other  conditions  of  a part,  heat  or  cold  are  respectively  calculated 
to  act  an  aesthetically.  But  I would  beg  to  make  this  general  re- 
mark, that  the  action  of  the  above,  and  of  other  applications,  which 
we  used  to  inflamed,  burned,  neuralgic,  and  pained  surfaces  and 
parts  (such  as  preparations  of  opium,  conium,  aconite,  belladonna, 
tobacco,  etc.  etc.),  still  require  to  be  studied,  which  they  have  not 
yet  been,  in  another  and  a new  light,  viz.,  as  local  anesthetics. 
Therapeutical  writers  will,  I believe,  betimes  consider  and  describe 
them  in  this  novel  point  of  view ; and  when  attention  comes  to  be 
directed  to  them  with  this  object,  some  new  facts  and  precepts  may 
be  elicited  that  will  enable  both  the  physician  and  surgeon  to 
exhibit  and  apply  local  anaesthetics  with  more  science,  precision,  and 
success,  than  hitherto. 

The  experiments  and  observations  which  I have  detailed  in  the 
preceding  pages,  perhaps  entitle  us,  in  the  present  state  of  our 
knowledge,  to  draw  the  following  conclusions  : — ^ 

Through  the  kiiidneas  of  Professor  Balfour,  I have  had  various  opportunities 


268 


LOCAL  ANESTHESIA. 


1.  In  animals  belonging  to  the  class  of  Articulata,  complete 
local  and  limited  anaesthesia  can  be  produced  by  the  local  an<l 
limited  application  of  the  vapour  or  liquid  of  chloroform  to  indi 
vidual  parts  of  the  body  of  the  animal. 

2.  In  Batrachian  reptiles,  the  tail,  or  an  individual  limb,  can  be 
affected  in  the  same  way  with  local  anaesthesia,  by  the  local  appli- 
cation of  the  chloroform ; but,  in  addition,  general  anaesthesia  of 
the  animals  usually  results  in  a short  time,  in  consequence  of  the 
chloroform  absorbed  by  the  exposed  part  coming  to  affect  the  general 
system. 

3.  In  the  smaller  Mammalia  a single  limb,  or  even  the  whole 
lower  or  pelvic  half  of  the  body,  can  be  rendered  anaesthetic  by 
local  exposure  of  these  parts  to  the  influence  of  chloroform. 

4.  In  the  human  subject,  partial,  and  perhaps  superficial,  local 
anaesthesia  of  a part,  as  the  hand,  can  be  produced  by  exposing  it 
to  the  strong  vapour  of  chloroform ; but  the  resulting  degree  of  this 
local  anaesthesia  is  not  sufficiently  deep  to  allow  the  part  to  be  cut 
or  operated  upon  without  pain. 

5.  Any  agent  possessing  a stronger  local  benumbing,  or  an 
anaesthetic  influence,  would  probably  be  dangerous,  by  its  acting 
too  powerfully  on  the  general  economy,  before  the  local  anaesthesia 
was  established  to  a depth  sufficient  for  operating. 

6.  Artificial  local  anaesthesia,  from  any  known  anaesthetic  agents, 
seems  objectionable  in  any  part  intended  to  be  operated  upon,  in 
consequence  of  the  vascular  congestion  and  injection  which  attend 
upon  and  accompany  this  local  anaesthesia. 

7.  There  are  few  operations  in  which  there  is  not  previously  a 
local  broken  surface  ; and  the  application  of  chloroform,  etc.,  to  such 
a surface,  would  be  far  too  painful  to  be  endured,  no  small  degree 
of  suffering  sometimes  arising  from  even  the  exposure  of  the  unbroken 
skin  to  their  action. 

of  trying  the  effect  of  chloroform  in  vapour  upon  the  sensitive  plant  {Mimosa 
pudica).  When  the  vapour  was  either  too  strong  or  too  long  continued,  the  plant 
was  destroyed.  When  it  was  weaker  and  applied  only  for  a few  minutes,  the 
leaflets  in  some  plants  closed  as  when  irritated,  and  did  not  expand  again  for  an 
unusual  length  of  time.  In  other  plants,  under  exposure  to  the  chloroform  vapour, 
no  closure  of  the  leaflets  took  place,  and,  in  a few  minutes,  the  plant  became  so 
anresthetised,  that  the  mechanical  or  other  irritation  of  the  leaflets  or  stalk  did 
not  produce  any  of  the  common  movements ; nor  did  their  irritability  become 
restored  for  a considerable  time  afterwards. 


CHLOKOFOllM. 


269 


CHAPTER  IV. 

PRACTICAL  APPLICATION  OF  CHLOROFORM  AS  A 
TOPICAL  ANESTHETIC  TO  MUCOUS  AND  CUTANEOUS  SURFACES. 

Edinburgh,  February  185G. 

In  1853,  Dr.  Hardy  of  Dublin  published  in  the  November 
number  of  the  Dablin  Quarterly  Journal  of  Medical  Science  an  in- 
teresting communication  on  the  same  subject,  entitled,  “ On  the 
Local  Application  of  the  Vapour  of  Chloroform  in  the  Treatment  of 
various  Diseases.” 

The  principal  peculiarity  in  Dr.  Hardy’s  essay  consisted  in  the 
proposal  of  a special  valved  instrument — the  Ancesthetic  Douche  as 
he  termed  it  ^ — for  the  purpose  of  applying,  in  an  intermittent 
stream,  the  vapour  of  chloroform  to  any  part  or  surface  that  was 
wished  to  be  affected. 

But  in  projecting  a stream  of  chloroform  vapour  upon  any  point, 
I have  generally  made  use  merely  of  a common  enema  syringe  ; and 
it  will  be  found,  I believe,  to  serve  as  well,  if  not  indeed  better, 
than  any  of  the  complex  and  expensive  special  instruments  invented 
for  the  purpose.  In  fact,  a larger  and  more  powerful  stream  of 
vapour  can  be  kept  up  by  an  enema  syringe  than  by  any  of  the 
special  anjesthetic  douches  which  I have  seen. 

Any  of  the  usual  forms  of  pea-valve  enema  syringe  will  answer 
the  purpose,  provided  their  lower  or  receiving  extremity  be  immersed 
in  the  vapour  of  chloroform,  and  the  instrument  worked  in  the  usual 
way  employed  for  the  transmission  of  water  or  other  liquids.  The 

^ Dr.  Hardy’s  original  Anrestlietic  Douche  “ was  formed  of  a caoutchouc  bottle, 
having  attached  to  one  side  of  it  a metallic  chamber  and  egress-pipe  provided  with 
two  valves  to  regulate  the  admission  and  the  egress  of  air  and  vapour.  The  metal- 
lic chamber  was  perforated  at  the  side  to  admit  a sponge  sprinkled  with  chloroform, 
and  this  perforation  was  closed  with  a screw  stopper.”  See  figure  of  the  instrument 
in  Dublin  Journal  of  Medical  Science  for  November  1853.  Subsequently  Dr. 
Hardy  invented  and  used  another  Anaesthetic  Douche,  far  more  complex  and  ex- 
pensive, of  which  he  has  given  a description  and  drawing  in  the  Dublin  Medical 
Press  for  April  1854.  It  was  proposed  to  take  out  a patent  for  the  Douche. — (See 
Medical  Press  for  April  26,  p.  268.) 


270 


LOCAL  ANESTHESIA. 


vapour  of  cliloroform,  etc.,  or  rather  of  air  loaded  with  the  vapour, 
passes  readily  through  the  canal  of  the  syringe,  and  is  projected  in 
an  intermittent  stream  from  its  orifice. 

The  syringe  which  I have  generally  used  for  this  purpose  is  the 
barrel  syringe  of  Mr.  Higginson.  It  consists  of  three  pieces  of 
caoutchouc  tubing,  the  middle  or  thickest  portion  being  provided 
at  either  extremity  with  the  common  pea  or  ball  valve,  and  al- 
together forms,  in  my  opinion,  by  far  the  simplest,  most  durable, 
and  at  the  same  time  the  cheapest  description  of  syringe  yet  sug- 
gested for  injecting  fluids  into  the  rectum  or  vagina.  When  used 
for  the  transmission  of  chloroform  vapour  it  requires  to  be  worked 
in  the  usual  way  for  the  transmission  of  liquids,  but  with  its  lower 
or  inferior  extremity  placed  in  air  loaded  with  the  vapour  of  chloro- 
form. In  order  to  effect  this  last  arrangement,  all  that  is  necessary 
is  to  place  this  lower  extremity  of  the  instrument  in  the  neck  of  a 
phial  or  bottle  containing  liquid  chloroform.  The  lower  extremity 
of  the  barrel  enema  syringe  is  generally  made  of  the  size  and  form 
of  the  two  last  joints  of  the  little  finger  ; and  the  tube  is  encircled 
with  a projecting  ridge  or  shoulder  above  this  point.  AVhen  em- 
ployed as  an  anaesthetic  douche,  this  finger-like  end  of  the  instru- 
ment is  passed  into  the  neck  of  a chloroform  bottle  sufficiently  large 
to  admit  it  easily  ; whilst  at  the  same  time  the  circular  projecting 
ridge  of  the  tube  rests  on  the  mouth  of  the  phial.  For  this  purpose 
the  common  six-ounce  phial  or  bottle,  with  a mouth  four  or  five 
lines  wide,  answers  perfectly.  An  ounce  of  chloroform  placed  in 
the  bottom  of  the  phial  will  enable  it  to  serve  as  an  anaesthetic 
douche  for  a long  time.  Before  using  it,  the  shaking  of  the  bottle 
will  impregnate  the  air  in  it  more  thoroughly  with  chloroform 
vapour.  When  patients  themselves  employ  the  syringe  and  bottle, 
perhaps  it  will  be  found  necessary  to  explain  to  them  that  they  are 
not  to  inject  the  liquid  chloroform  through  the  tube,  but  only  the 
vapour  of  it,  or  rather  air  loaded  with  the  vapour. 

The  preceding  simple  arrangement  converts  a common  enema  or 
vaginal  syringe  into  an  anaesthetic  douche,  equally,  or  indeed  more, 
powerful  than  the  ingenious  instrument  specially  invented  by  Dr. 
Hardy  for  the  purpose.  As  a proof  of  this,  let  me  merely  state,  that 
in  various  trials  upon  various  individuals,  I have  never  seen  the 
stream  of  vapour  from  Dr.  Hardy’s  instrument,  when  fully  charged, 
produce  a state  of  general  anaesthesia  when  the  jet  from  it  was  pro- 
jected into  the  mouth ; but  I have  found  that  result  to  follow  in 
some  instances  when  the  same  experiment  was  made  with  the 


CHLOROFORM.  271 

stronger  and  more  sustained  stream  of  chloroform  vapour  sent 
through  the  common  syringe. 

When  the  inferior  end  of  the  enema  syringe  employed  is  of  such 
a shape  that  it  will  not  pass  into  the  neck  of  a bottle  containing 
chloroform,  other  arrangements  may  be  required  to  supply  it  with 
chloroform  vapour.  For  this  purpose  the  lower  end  of  the  S3Tinge 
may  be  placed  upon  the  hollow  of  a concave  sponge  bedewed  with 
chloroform ; or  a piece  of  lint,  flannel,  or  the  corner  of  a handker- 
chief, or  other  such  material,  freely  wetted  with  it,  may  be  lightly 
rolled  around  the  lower  extremity  of  the  instrument.  Sometimes, 
with  the  same  view,  I have  placed  the  end  of  the  syringe  in  the 
bottom  of  a cup  or  tumbler  in  which  there  was  a bit  of  sponge  or 
lint  soaked  with  chloroform ; for  the  vapour  of  chloroform  being 
nearly  four  times  heavier  than  atmospheric  air,  fills  always  the  lower 
part  of  such  a vessel.  By  any  of  these  means  a sufficient  quantity 
of  chloroform  vapour  can  be  supplied  to  fill  the  instrument,  and  to 
make  a stream  of  it  pass  from  its  superior  orifice,  when  the  syringe 
is  worked  in  the  usual  manner  for  transmitting  liquids. 

I have  used  the  injection  of  chloroform  vapour  into  the  vagina 
by  the  preceding  method  in  many  cases  of  painful  and  neuralgic 
conditions  of  the  uterine  and  pelvic  organs.  In  most  instances, 
after  the  first  sensations  of  warmth  produced  by  the  injection  have 
passed  away,  relief  has  been  found  to  follow  for  a greater  or  less 
length  of  time  ; and  to  sustain  this  state  of  freedom  from  suffering, 
the  injection  has  generally  required  to  be  repeated  by  the  patient 
after  the  lapse  of  a few  hours.  This  treatment  has  appeared  to  me 
more  particularly  useful  in  neuralgic  states  of  the  uterine  organs  and 
passages  ; in  those  organic  diseases  that  are  occasionally  accompanied 
with  suffering,  as  carcinoma  uteri ; in  some  cases  of  severe  feelings 
of  bearing  down,  and  incapacity  to  stand  and  walk,  complicated  with 
displacements  and  enlargements  of  the  uterus ; and  in  various  spas- 
modic conditions  of  the  uterus  attended  with  pain,  as  in  threatened 
abortions ; in  after-pains ; and  most  markedly  in  severe  dysme- 
norrhoea.  But  at  the  same  time  I would  beg  to  remark  that  in 
various  instances  in  which  the  preceding  morbid  states  were  present, 
and  in  which  I fully  expected  the  usual  anodyne  effect  of  the  vapour 
to  be  experienced,  the  treatment  has  failed  to  give  the  usual  relief  j 
probably  because  the  mere  superficial  an?esthesia  which  results  from 
the  aneesthetic  vapour  was  not  sufficient  in  depth  or  in  degree  to 
produce  an  anodyne  effect.  In  other  instances,  on  the  contrary,  in 
consequence,  perhaps,  of  the  peripheral  extremities  of  the  nerves 


272 


LOCAL  ANiESTHESIA. 


distributed  to  the  genital  mucous  surface  being  specially  affected,  or 
having  a special  reflex  influence  upon  the  deeper-seated  parts  and 
pains,  the  chloroform  vapour  has  succeeded  not  only  in  producing 
temporary  relief,  but  in  producing  even  a speedy  and  a permanent 
cure,  under  circumstances  where  the  previous  duration  and  severity 
of  the  symptoms  seemed,  a priori,  to  forbid  the  hope  of  a restoration 
to  health  by  this  means  alone.  I had,  for  example,  lately  under  my 
care  a patient  who,  in  consequence  of  severe  pelvic  or  uterine  pain, 
had  been  obliged  to  keep  the  supine  position  upon  the  bed  or  sofa 
for  nearly  six  months  previously.  All  attempts  at  standing  or 
walking  brought  on  renewed  paroxysms  of  suffering.  The  uterus 
w'as  slightly  retroverted,  but  otherwise  apparently  liealthy.  After 
being  brought  with  some  difficulty  to  Edinburgh  from  a distant  part 
of  England,  the  only  treatment  to  which  she  was  subjected  consisted 
of  the  injection  of  chloroform  vapour  several  times  a-day  into  the 
vagina,  which  at  once  relieved,  and  ultimately  altogether  removed, 
the  uterine  pains.  Within  a week  the  morbid  sensibility  of  the 
parts  entirely  disappeared.  There  was,  about  a month  subsequently, 
a short  relapse,  in  consequence  of  indiscretion  in  exercise  and  ex- 
posure to  cold,  but  the  attack  speedily  yielded  to  the  same  treat- 
ment. I never  had  the  pleasure  of  'watching  such  a speedy  and 
perfect  restoration  to  health  and  happiness  from  that  state  of  hyste- 
ralgia  which  so  often  entails  upon  patients  misery  and  suffering  for 
long  months  and  years. 

I have  repeatedly  applied  chloroform  to  the  maternal  passages 
during  labour  in  cases  of  rigidity  of  these  passages,  and  particularly 
in  rigidity  of  the  cervix  uteri  when  co-existing  with  morbid  irrita- 
bility and  sensibility  of  the  parts.  In  these  instances  I have  used 
sometimes  the  chloroform  vapour  injected  by  the  usual  means; 
sometimes  a few  drops  of  fluid  chloroform,  mixed  up  with  oil,  or  with 
a small  solid  mass  of  butter  or  ointment.  The  practice  has  appeared 
to  me  to  be  very  often  followed  by  two  beneficial  results — first,  the 
abatement  of  the  supersensibility  of  the  maternal  canals ; and 
secondly,  very  often  also  with  an  increased  secretion  of  mucus,  and 
apparently  an  increased  susceptibility  to  relaxation  and  dilatation 
in  the  rigid  structures.^ 

^ Note  on  the  mode  of  dilatation  of  the  maternal  2mssages  in  labour. — During 
parturition  tlie  maternal  canals — viz.  the  cervix  uteri,  vagina,  and  vulva — are, 
no  •doubt,  dilated  principally  by  the  results  of  muscular  uterine  action  and  me- 
chanical pressure.  But  they  evidently  become  also  dilatable  and  relaxed  by 
another  and  an  additional  process,  which  is  so  far  independent  both  of  muscular 


CHLOEOFORM. 


273 


In  the  preceding  remarks  I have  hitherto  spoken  of  chloroform 
when  applied  as  a local  anaesthetic  to  the  genital  mucous  canals. 
Its  local  anaesthetic  action  on  other  mucous  surfaces  has  not  yet 
been  much  studied.  I have  seen,  however,  the  injection  of  the 
vapour  of  chloroform  into  the  rectum  useful  also  in  some  instances 
of  morbid  irritability  and  sensibility  of  the  lower  end  of  the  intes- 
tinal canal,  in  tenesmus,  etc.  The  mucous  membrane  of  the  eye 
seems  in  most  individuals — especially  in  its  diseased  states — too 
irritable  to  bear  the  contact  of  very  concentrated  chloroform  vapour, 
such  as  I employed  in  some  early  experiments  alluded  to  in  the 
last  chapter;  but  in  cases  of  photophobia  and  supersensibility 
to  light  connected  with  scrofulous  ophthalmia,  etc.,  the  vapour  of 
chloroform  diluted  with  air  or  aqueous  vapour,  acts  sometimes  very 
markedly  and  beneficially  as  a local  anresthetic.  I have  seen  the 
intolerance  of  light  connected  with  ulcerative  corneitis  at  once  re- 
lieved by  exposing  the  eye  to  the  vapour  of  chloroform,  raised  by 
pouring  a small  quantity  of  the  fluid  into  a cup  of  warm  water.  The 
patient  will  thus  sometimes  immediately  be  enabled  to  open  the  eye 
freely  and  without  pain  ; and  the  chloroform  vapour  often  serves  also 
as  the  best  possible  medicinal  application  to  the  ulcerated  surface.’ 
The  dentist  can  occasionally  relieve  the  pain  of  toothache,  by  the 
local  anaesthesia  resulting  from  the  application  of  a drop  of  fluid 
chloroform  to  the  exposed  interior  of  the  tooth ; or  by  directing  a 
action  or  mechanical  pressure.  In  proof  of  this,  we  find  the  whole  length  of  the 
canal  of  the  vagina  relaxing  and  widening  during  a protracted  labour,  before  the 
head  has  yet  passed  the  brim,  or  fully  opened  the  os  uteri.  This  vital  process  of 
dilatation  seems  to  me  to  consist  of  a rapid  development  of  cells  within  the  tissues 
of  the  walls  of  the  maternal  canals— just  as  the  thick  mucous  secretion  thrown  out 
upon  the  free  surface  of  these  canals  during  labour  (and  indicative,  when  present 
in  great  quantity,  of  great  dilatability  in  these  canals)  is  essentially,  and  in  its 
ultimate  physiological  analysis,  a rapid  development  of  cells  upon  the  free  surface 
of  their  mucous  coat.  The  application  and  stimulus  of  various  substances,  as  simple 
warm  water,  of  warm  aqueous  vapour,  oils,  simple  or  stimulant,  etc.,  apparently 
promotes  the  dilatability  of  the  tissues  of  the  cervix  uteri  and  vaginal  canals,  by 
promoting  probably  the  more  rapid  formation  of  these  cells.  And  from  A'^arious 
cases  which  I have  seen,  I am  led  to  believe  that  chloroform,  both  in  the  form  of 
vapour,  or  of  fluid  diluted  with  oil  or  lard,  will  be  found  specially  successful  in 
producing  this  result,  or  at  least — be  the  explanation  Avhat  it  may — in  producing 
the  required  relaxation  in  cases  of  anormal  or  morbid  rigidity. 

* The  vapour  of  prussic  acid  carefully  applied  to  the  eye,  by  means  of  a proper 
cup  or  glass,  acts  probably  upon  the  same  principle.  It  was  much  recommended 
some  years  ago  by  Dr.  Turnbull ; but  indiscriminately  in  almost  all  ocular  diseases. 
From  what  I have  seen  in  practice,  I believe  that  the  use  of  dilute  chloroform 
vapour  and  of  carbonic  acid  will  become  common  in  affections  of  the  cornea  and 
conjunctiva  connected  with  intolerance  of  light  and  supersensibility.  They  both 
act  not  as  powerful  local  anaisthetics  merely,  but  also  as  excellent  medicinal  ap- 
plications to  any  existing  ulcers,  etc. 


274 


LOCAL  ANJ2STHESIA. 


stream  of  chloroform  vapour  upon  it.  In  painful  and  spasmodic 
states  of  the  respiratory  canals,  when  chloroform  is  applied  to  their 
mucous  surfaces  by  inhalation,  it  is  difficult,  or  indeed  impossible, 
to  tell  always  whether  the  resulting  relief  is  the  effect  of  local  or  of 
general  anaesthesia.  In  some  cases  of  spasmodic  asthma,  relief  is 
occasionally  obtained  by  doses  too  slight  to  have  acted  by  any  general 
anaesthetic  effects ; but  I have  seen  other  instances  of  the  same 
disease  where  the  paroxysm  was  not  effectually  arrested  till  a com- 
plete state  of  general  anaesthesia  was  produced.  A similar  observa- 
tion holds  true  with  regard  to  different  cases  of  laryngismus.  Some- 
times that  troublesome  affection,  hysterical  or  spasmodic  aphonia,  is 
at  once  cured  by  a few  inhalations  of  chloroform  vapour,  acting 
perhaps  as  much  upon  the  principle  of  a local  as  of  a general 
anaesthetic.  The  irritability  of  the  cough  in  cases  of  phthisis,  bron- 
chitis, pneumonia,  etc.,  is  often  effectually  relieved  by  doses  apparently 
too  small  to  have  acted  otherwise  than  as  local  anjesthetics.  Lastly, 
in  reference  to  the  topical  ansesthetic  influence  of  chloroform  upon 
mucous  membranes,  let  me  add,  that  the  swallowing  of  a few  drops 
of  fluid  chloroform  in  oil,  cream,  soda  water,  or  any  other  convenient 
vehicle,  sometimes  speedily  abates  nausea,  vomiting,  obstinate  hiccup, 
etc. — perhaps  upon  the  principle  of  its  acting  as  a local  and  limited 
anaesthetic  upon  the  walls  of  the  stomach. 

The  preceding  observations  are  limited  to  the  local  anaesthetic 
effect  of  chloroform  upon  mucous  surfaces  and  canals.  On  the  skin 
it  produces  a topical  action,  similar  in  principle,  but  far  less  in 
degree.  When  the  epidermis  is  removed,  or  when  the  skin  itself  is 
destroyed,  the  surface  of  any  existing  sore,  such  as  an  irritable 
abrasion,  an  excoriated  nipple,  or  a benign  or  carcinomatous  ulcer, 
can  be  very  remarkably  anaesthetised  and  benumbed  by  the  local 
application  of  chloroform  vapour ; but  the  feelings  of  great  heat 
and  pain,  which  in  the  first  moments  accompany  its  application, 
more  than  counterbalance,  in  most  subjects,  the  subsequent  sedative 
effects  derivable  from  its  use.  The  various  experiments  which  I 
have  detailed  in  the  preceding  chapter  show  that  chloroform  fluid  or 
vapour,  when  applied  to  the  unbroken  human  skin,  produces  a 
degree  and  depth  of  local  anaesthesia,  that  is  sufficiently  great  to  be 
sometimes  useful  in  medicine,  while  it  is  not  sufficiently  great  to  be 
useful  in  operative  surgery.  In  medicine,  for  example,  the  local 
anaesthetic  effects  of  chloroform  often  prove  most  beneficial  in  local 
neuralgia,  local  rheumatism,  etc.  ; and  chloroform  mixed  with  equal, 
or  with  varying  parts  of  olive  oil,  according  to  the  sensitiveness  of 
the  patient’s  skin,  is  sometimes,  in  such  cases,  the  most  efficient 


CHLOROFORM. 


275 


form  of  cutaneous  topical  anodyne  which  we  can  employ.  The 
amount  of  local  ansesthesia,  however,  thus  capable  of  being  produced, 
is  not,  as  I have  just  stated,  by  any  means  deep  enough  to  enable 
the  patient  to  endure  any  operative  or  surgical  procedure.  In  the 
earlier  part  of  1854,  however,  a variety  of  experiments  was  made 
in  the  Parisian  hospitals,  under  the  full  belief  that  a stream  of 
chloroform  vapour  projected  against  the  skin  might  produce  such  an 
amount  of  local  anaesthesia  in  any  given  part  of  the  cutaneous  sur- 
face, as  would  allow  that  surface  to  be  cut  or  operated  upon  by  the 
surgeon,  without  pain  to  the  patient.  Dr.  Hardy’s  ana3sthetic  douche, 
or  some  modification  of  it,  was  the  instrument  usually  employed  in 
these  experiments.  Several  alleged  cases  of  the  perfect  success  of 
this  local  cutaneous  anaesthesia  were  published  in  the  French 
journals.  It  was  averred,  for  example,  that  M.  Dubois  had  opened 
with  the  knife,  and  without  pain,  an  abscess  in  the  axilla,  that  M. 
Nelaton  opened  an  abscess  in  the  foot — the  vapour  of  chloroform 
having  in  each  case  been  previously  applied  to  the  skin  ; and  that 
M.  Dan y an,  also  without  pain,  made  a caustic  issue  on  the  neck — 
the  skin  being  prepared  by  the  anjesthetic  douche.  But  additional 
trials  very  speedily  proved  the  inutility  of  the  practice,  as  far  at 
least  as  the  possibility  of  producing  by  it  immunity  from  the  pain 
of  surgical  operations  was  concerned.  At  the  end  of  these  trials,  in 
commenting  upon  the  subject  in  the  Parisian  hospitals,  M.  Latour, 
the  learned  editor  of  the  Union  Medicale,  observes — “ I have  felt,  I 
avow,  distressed  and  humbled  with  all  the  noise  that  has  been 
made,  and  with  the  recital  of  all  the  numerous  experiments  that 
have  been  tried  in  this  matter.  I have  not  desired  to  accumulate 
the  record  of  them  here  ; and  I would  wish  that  all  trace  of  these 
facts  were,  for  the  honour  of  French  physiology,  blotted  out  as 
speedily  as  possible.”^ 

In  fact,  the  whole  of  these  experiments  and  inquiries  into  the 
possibility  of  producing  a sufficient  amount  of  local  ansesthesia  for 
surgical  purposes,  by  applying  chloroform  to  the  unbroken  skin, 
resulted  in  the  conclusion  which  I had  already  ventured  to  publish 
several  years  previously,  namely,  that  “ in  the  human  subject,  partial, 
and  perhaps  superficial  local  ansesthesia  of  a part,  as  the  hand,  can 
be^  produced  by  exposing  it  to  the  strong  vapour  of  chloroform  ; but 
the  resulting  degree  of  the  local  ansesthesia  is  not  sufficiently  deep 
to  allow  the  part  to  be  cut  or  operated  on  without  pain.”^ 

^ L' Union  Medicalc  for  4tli  ^Marcli  1854. 

- Sec  this  and  other  conclusions  anteriorly,  p.  268. 


276 


LOCAL  ANAESTHESIA. 


CHAPTER  V. 

CARBONIC  ACID  GAS  AS  A LOCAL  ANaESTHETIC. 

Edinhirgh,  1856. 

Carbonic  acid  is  usually  recognised  by  toxicologists  as  a very 
powerful  narcotic  poison,  when  inhaled  in  sufficient  quantity.  The 
rapidity  and  potency  with  which  it  acts  as  a general  anaesthetic 
have  long  been  described  by  travellers  in  the  experiment  of  tem- 
porarily plunging  a dog  into  an  atmosphere  of  carbonic  acid  in  the 
Grotto  del  Cane,  at  Pozzuoli. 

Carbonic  acid  gas  acts  also  as  a local  anodyne  or  anaesthetic. 
The  anaesthetic  effect  of  a stream  of  carbonic  acid,  when  applied 
locally,  is  easily  proved  by  holding  an}^  exposed  portion  of  the  sur- 
face of  the  body  where  the  skin  is  thin — as  the  wrist  or  forearm — 
over  a jet  of  the  gas,  escaping  from  a common  gas-receiver.  In  a 
minute  or  two,  the  surface  of  the  exposed  part  will  be  found  be- 
numbed, as  when  it  is  exposed  to  the  vapour  of  chloroform  ; and 
pinching  or  irritating  it  is  not  followed  with  so  much  pain  as  a 
similar  amount  of  pinching  and  irritation  applied  to  the  opposite 
and  unexposed  wrist  or  forearm.  The  degree  of  local  anaesthesia 
capable  of  being  produced  in  this  way  by  the  vapour  of  chloroform, 
applied  to  a portion  of  the  cutaneous  surface,  is,  as  I have  already 
stated,  not  by  any  means  deep  and  complete ; but,  in  the  relative 
experiments  which  I have  made,  it  has  generally  appeared  to  me  to 
be  greater  when  a jet  of  carbonic  acid  gas  was  used,  than  when 
chloroform  vapour  was  employed.  And,  like  chloroform  and  other 
analogous  agents,  carbonic  acid  gas  acts  more  powerfully  wlien 
applied  locally  to  mucous,  than  when  applied  to  cutaneous  surfaces. 

In  one  respect,  carbonic  acid  will  be  found  preferable  to  chloro- 
form vapour  as  a topical  anaesthetic  to  the  vagina  and  uterus. 
Though  the  application  of  the  vapour  of  chloroform  to  the  mucous 
membranes  of  the  mouth,  nose,  pharynx,  and  bronchi,  in  the  way  in 
which  it  is  usually  inhaled,  does  not  produce  any  very  marked  feel- 
ing of  warmth  in  these  mucous  surfaces  ; yet,  its  introduction  into 
the  genital  mucous  canals  generally  creates  a disagreeable,  and,  in 


CARBONIC  ACID. 


2V7 


some  instances,  a very  painful,  though  temporary  feeling  of  heat 
and  burning.  The  injection  of  carbonic  acid  gas  into  the  vagina  is 
not  followed  by  any  such  painful  sensation. 

I have  used  carbonic  acid  as  a local  anaesthetic,  principally  in 
neuralgia  of  the  vagina  and  uterus,  in  dysmenorrhoea,  and  in  morbid 
states  of  the  pelvic  organs  accompanied  with  pain,  as  in  carcinoma, 
etc.  I have  found  it  also  sometimes  of  use  in  irritable  states  of  the 
neighbouring  organs.  Two  years  ago  I had  under  my  care  from 
Canada  the  wife  of  a medical  gentleman,  who  was  suffering  much 
from  that  most  distressing  disease — dysuria  and  irritability  of  the 
bladder.  Many  modes  of  treatment  had  been  tried  in  vain.  The 
injection  of  carbonic  acid  gas  into  the  vaginal  canal  several  times 
a-day  at  once  produced  relief,  and  ultimately  effected  a perfect  cure. 
She  has  remained  well  since  her  return  to  America,  and  lately 
became  a mother.  Occasionally  relief  follows  immediately.  In  two 
or  three  instances  I have  seen  the  use  of  the  gas  continued  daily  for 
months.  I have  notes  of  one  case  where  the  patient  was  invalided 
and  almost  entirely  kept  to  the  supine  posture  for  years,  from  feel- 
ings of  pain  and  bearing  down  in  the  uterus  and  neighbouring  parts, 
particularly  on  attempting  to  sit  or  walk.  Many  modes  of  treat- 
ment were  tried  by  myself  and  others,  with  little  or  no  benefit. 
She  has,  however,  at  last  regained  in  a great  measure  the  power  of 
progression,  and  freedom  from  suffering  in  the  erect  posture — a 
result  which  she  herself  ascribes  to  the  local  application  of  carbonic 
acid  gas,  which  I recommended  to  her  some  months  ago ; and  in 
the  use  of  it  she  has  since  regularly  persevered. 

Since  applying  carbonic  acid  as  a local  anjesthetic  application  in 
uterine  disease,  I have  met  with  two  or  three  notices  of  this  use  of 
it  by  modern  authors.  In  his  work  on  Diseases  of  Females,  published 
in  1835,  the  late  Dr.  Dewees,  of  Philadelphia,  when  discussing  the 
treatment  of  carcinoma  uteri,  observes,  “ We  have  enabled  several 
patients  to  derive  much  comfort,  as  well  as  temporary  relief,  from 
the  extrication  of  carbonic  acid  gas  within  the  cavity  of  the  vagina, 
by  means  of  a flexible  tube  of  sufficient  length  and  size,  attached 
to  the  mouth  of  a bottle,  in  which  there  is  mixed  diluted  sulphuric 
acid  and  the  carbonate  of  lime.  This  may  be  introduced  into  the 
vagina  several  times  in  the  twenty-four  hours.  In  two  or  three 
instances  this  substance  has  relieved  the  severity  of  pain  whenever 
it  was  employed,  as  well  as  diminished  the  offensiveness  of  the 
discharge.”  ^ 

^ Treatise  on  the  Diseases  of  Females,  p.  269. 


278 


LOCAL  ANAESTHESIA. 


In  cases  of  painful  menstruation  or  dysmenorrhoea,  Professor 
Mojon  of  Geneva  has  recommended  the  local  application  of  carbonic 
acid  gas.^  Dr.  Mojon  states  that  in  the  disease  in  question  he  has 
employed  the  injection  of  carbonic  acid  gas  into  the  vagina  in  a 
great  number  of  instances,  and  generally  with  decided  advantage, 
the  pain  being  almost  always  relieved  by  this  treatment.  He  directs 
the  remedy  to  be  used  two  or  three  times  a-day,  and  for  five  or  six 
minutes  each  time.  Like  Dr.  Dewees,  he  recommends  the  gas  to 
be  obtained  by  pouring  dilute  sulphuric  acid  on  some  pieces  of  chalk 
in  a flask,  from  which  a curved  flexible  tube  carries  it  into  the 
vagina. 

In  a paragraph  which  I have  cited  in  a preceding  chapter,  from 
the  second  edition  of  the  work  of  Dr.  Pereira,  on  Materia  Medica, 
carbonic  acid  is  described  as  having  acted  speedily  and  beneficially 
in  one  case  as  a local  sedative  in  uterine  pain.  “A  lady,”  he  ob- 
serves, “who  had  suffered  a considerable  time  from  some  uterine 
affection,  and  had  derived  no  relief  from  the  treatment  adopted,  was 
advised  to  consult  a physician  in  Italy  (Dr.  Eossi).  After  he  had 
examined  the  condition  of  the  uterus,  he  assured  her  there  was  no 
organic  disease,  but  merely  a considerable  degree  of  irritation,  for 
which  he  proposed  to  apply  carbonic  acid  as  a sedative.  This  was 
done  by  means  of  a pipe  and  tube,  communicating  with  a gasometer 
situated  in  another  room.  The  patient  obtained  immediate  relief, 
and  although  she  had  been  obliged  to  be  carried  to  the  doctor’s 
house  on  account  of  the  pain  experienced  in  walking,  she  left  it  in 
perfect  ease.  On  her  return  to  England  she  had  a relapse  of  the 
complaint,  and  applied  to  Dr.  Clutterbuck  to  know  whether  she 
could  have  the  same  remedy  applied  in  London,  in  order  to  save 
her  the  necessity  of  returning  to  Italy.”  ^ This  case  and  paragraph, 
however,  seemed  to  Dr.  Pereira  of  so  little  value,  that  he  has 
omitted  the  details  of  it  in  the  last  edition  of  his  work.  But 
from  the  time  of  reading  it  I have  tried  at  various  times,  and  more 
particularly  during  the  last  two  or  three  years,  the  local  application 
of  carbonic  acid  to  the  mucous  membrane  of  the  vagina  and  cervix 
uteri  in  different  painful  conditions  of  the,  uterus  and  neighbouring 
parts  ; and,  whilst  it  has  failed  in  some  instances  to  afford  the 
expected  relief,  it  has  in  others  proved,  as  I have  already  stated,  of 
great,  and  occasionally  of  almost  instantaneous  benefit. 

In  practice  I have  generally  used  a common  wine-bottle  for  the 

1 Bulletin  de  Tlicrcqjeutique. — American  Journal  of  Medical  Sciences,  vol.  xiii. 
p.  469.  ^ Elements  of  Materia  Mcdica,  vol.  i.  p.  155. 


CARBONIC  ACID. 


279 


formation  of  the  carbonic  acid  gas,  and  formed  the  gas  by  mixing 
in  the  bottle  six  drachms  of  crystallised  tartaric  acid  with  a solution 
of  eight  drachms  of  bicarbonate  of  soda,  in  six  or  seven  ounces  of 
water.  A long  flexible  caoutchouc  tube  conducts  the  gas  from  the 
bottle  into  the  vagina.  The  cork  fixing  this  tube  into  the  mouth 
of  the  bottle  should  be  adapted  so  as  to  prevent  any  escape  of  the 
gas  by  its  sides.  With  this  view  the  cork  should  be  perforated  by 
a metallic  tube,  and  covered  externally  with  a layer  of  caoutchouc. 

The  use  of  carbonic  acid  as  a local  anaesthetic  to  the  uterine 
mucous  surfaces  and  to  other  parts  of  the  body  is  not  a discovery 
of  late  times.  I have  found  that  in  this,  as  in  many  other  examples, 
what  appeared  to  me  at  first  novel,  was,  when  fully  investigated,  a 
practice  known  previously  in  its  essence,  and  perhaps  in  its  more 
minute  details  also.  Besides,  here,  as  elsewhere,  w’hen  once  we 
detect  a principle,  such  as  the  anaesthetic  power  of  carbonic  acid  gas 
when  applied  topically,  we  can  explain  by  it  the  good  effects  of 
modes  of  practice,  which  previously  perhaps  we  w^ere  inclined  to 
ridicule  and  reject. 

1.  In  some,  for  example,  of  our  oldest  works  on  female  diseases, 
as  in  the  Hippocratic  writings,^  and  in  the  chapters  of  Paulus 
H^gineta,^  Ruefi’,'^  Parc,^  etc.,  referring  to  uterine  affections,  directions 
are  given  for  the  relief  of  local  pains,  etc.,  in  the  uterus,  by  a 
system  of  practice  which  at  least  included,  and  perhaps  which 
essentially  consisted  of  the  local  application  of  carbonic  acid  gas  to 
the  mucous  membrane  of  the  genital  canals.  I allude  to  the  burn- 
ing of  various  herbs,  aromatic  and  medicinal,  and  the  application  of 
the  fumes  arising  from  their  combustion,  by  appropriate  tubes  and 
instruments,  to  the  interior  of  the  vagina.  It  is  now  known  to  all 

^ See  Kuhn’s  edition  of  Ilip^tocratcs,  vol.  ii.  Dc  Natura  Miilichri,  pp.  567, 
597,  etc.  De  Morhis  Mulicrum,  p.  859,  etc.  “ Theophilus  describes  the  process 
very  minutely,  but  it  will  be  readily  understood  that  it  consisted  in  introducing 
the  fumes  of  strong-smelling  things,  such  as  frankincense,  spikenard,  cassia,  and 
storax,  into  the  vagina  by  nn;ans  of  a funnel.”  Dr.  Adams’s  edition  of  the  works 
oi  Hippocrates^  vol.  ii.  pp.  742  and  748.  See  also  on  the  Hippocratic  method  of 
fumigating  the  mucous  surface  of  the  vagina,  Halle  and  Kysten  in  Diction,  dcs 
Sciences  Meclicalcs,  vol.  xvii.  p.  135. 

2 Adams’s  edition  of  Paulus  JEgincta,  vol.  i.  p.  642,  etc. 

* The  Expert  Midwife  (1637),  compiled  in  Latin,  by  James  Euelf,  part  ii.  p. 
52,  etc. 

^ Johnston’s  Translation  of  the  Whole  Works  of  Ambrose  Pare.,  p.  944,  with  a 
description  and  figure  of  “ a vessel  made  with  a fiinnell  or  pipe  for  to  fumigate 
the  wombe.” 

V4 


280 


LOCAL  ANESTHESIA. 


that  the  combustion  of  dried  plants  and  vegetable  substances  gives 
rise  to  the  formation  of  carbonic  acid ; and  the  fumigations  of  the 
ancients,  when  they  acted  beneficially,  probably  acted  much  more 
by  the  mere  topical  application  of  this  gas,  than  by  anything 
aromatic  or  medicinal  contained  in  the  smoke  of  the  burned  in- 
gredients. 

2.  Further,  the  knowledge  of  the  marked  local  ansesthetic  effects 
of  carbonic  acid  gas  appears  to  me  to  explain  the  good  effects  some- 
times derived  from  a system  of  modern  practice  regarding  which  I 
formerly  felt  great  scepticism.  I have  been  often  assured  by  patients 
of  the  soothing  and  sedative  effects  of  the  direct  injection  from  the 
spring,  of  streams  of  various  mineral  waters,  as  practised  at  different 
German  baths.  It  always  seemed  to  me  impossible  that  the  slight 
amount  of  alkaline  salts  which  these  injection  baths  or  streams  con- 
tain, could  be  followed  by  the  sedative  effect  so  often  ascribed  to 
them.  But  from  the  inquiries  that  I have  made,  I believe  it  will  be 
found  that  all  the  mineral  waters  which,  when  locally  applied,  pro- 
duce this  sedative  or  anaesthetic  effect,  contain  a greater  or  less 
quantity  of  free  carbonic  acid,  rapidly  and  constantly  escaping  from 
them ; and  the  practice  in  its  true  therapeutic  analysis  probably 
consists  only  of  the  local  application,  in  a somewhat  clumsy  form,  of 
carbonic  acid  to  the  genital  mucous  surfaces.  At  some  of  the  German 
watering-places,  as  !Neuheim,  Marienbad,  etc.,  the  large  quantities  of 
carbonic  acid  thrown  off  from  the  mineral  .wells  has  latterly  been 
collected,  and  applied  per  se  in  the  form  of  baths,  jets,  and  streams, 
to  different  parts  of  the  cutaneous  and  mucous  surface — as  to  the 
uterus  in  neuralgia,  etc.,  to  the  limbs  when  ulcerated,  to  the  eye  in 
irritable  chronic  ophthalmia,  etc.  etc.  These  uses  of  carbonic  acid 
have  been  followed  out,  without,  I believe,  any  tenable  rationale 
having  been  suggested  of  the  probable  mode  of  action  of  the  treat- 
ment. The  utility  of  the  practice,  which  I have  been  assured  by  my 
friend  Dr.  Funck  of  Frankfort  is  most  marked  in  some  diseased 
states,  will  find,  I believe,  its  true  explanation  in  the  local  anaes- 
thetic effect  of  carbonic  acid.  And  if  so,  it  is  scarcely  necessary  to 
add,  the  remedy  may  be  artificially  made,  and  readily  applied  at  any 
time,  and  at  any  place,  and  in  the  practice  of  any  physician. 

3.  A knowledge  of  the  topical  anaesthetic  effects  of  carbonic  acid 
serves  perhaps  also  to  afford  an  explanation  of  other  points  in  common 
therapeutics.  There  are,  for  example,  circumstances  in  medical  prac- 


CARBONIC  ACID. 


281 


tice  in  which  we  either  incidentally  or  intentionally  apply  carbonic 
acid  to  the  gastric  and  intestinal  mucous  membrane.  In  gastric 
irritability  and  nausea,  physicians,  since  the  time  of  Kiverius,^  have 
constantly  been  in  the  habit  of  prescribing  effervescing  saline  draughts, 
or  artificial  aerated  waters,  which  throw  off  a great  quantity  of  car- 
bonic acid,  after  their  introduction  into  the  stomach.  In  some 
instances  the  antacid  action  of  the  alkali  may  explain  this  effect ; 
but  is  not  the  sedative  action  of  these  draughts,  in  most  instances, 
dependent  upon  the  local  anaesthetic  effect  upon  the  mucous  surface 
of  the  stomach  of  the  large  quantities  of  carbonic  acid  which  they 
eliminate  ? 

Dr.  Pereira  refers  to  Mr.  Parkins’s  late  recommendation^  of  the 
topical  application  of  carbonic  acid  gas  as  a clyster  in  dysentery  and 
diarrhoea.  But  neither  Dr.  Pereira  nor  Mr.  Parkins  seems  to  be  aware 
that  the  practice  is  not  altogether  novel.  As  long  ago  as  1772,  in  a 
case  of  diarrhoea,  complicating  continued  fever,  Mr.  Hey  of  Leeds 
threw  up  into  the  rectum,  on  two  successive  days,  injections  of  car- 
bonic acid  gas.  This  practice  had,  as  he  supposed,  the  best  effects — 
both  the  frequency  and  foetor  of  the  stools  being  apparently  di- 
minished by  it.*  Dr.  Percival  of  Manchester  also  published  in  Dr. 
Priestley’s  work  “ two  similar  instances  of  the  salutary  effects  of 
mephitic  air  thus  administered  as  an  enema.”  The  same  practice 
was  also  adopted  in  the  last  century  by  Dr.  Warren  of  Taunton,^ 
and  Dr.  Eotheram.*  “ May  we  not,”  asks  Dr.  Percival,  “ presume 
that  the  same  remedy,  viz.  enemata  of  carbonic  acid  gas,  would  be 
equally  useful  in  dysentery  1 ® Dr.  Henry  subsequently  recorded 
two  cases  of  dysentery  in  which  the  use  of  carbonic  acid  clysters 
was,  in  his  opinion,  followed  by  very  marked  relief  of  the  abdo- 
minal pains  and  swelling,  and  a diminution  of  the  foetor  of  the 
discharges.'^ 

^ The  celebrated  anti-nauseant  and  anti-emetic  potion  of  Riverius  was  composed 
of  a solution  of  a scruple  of  salt  of  wormwood  (an  impure  carbonate  of  potass), 
mixed  with  a table-spoonful  of  lemon-juice.  He  describes  it  as  a “reniedium 
prffistantissimum,  prsesertim  in  vomitu  qui  febribus  malignis  solet  contingere.  ” — 
Praxis  Mcdica,  lib.  ix.  cap.  7 ; ct  Centuria  Ohservationum,  obs.  15. 

2 On  the  Efficacy  of  Carbonic  Acid  Gas  in  the  Diseases  of  Tropical  Climates, 
etc. — London  Medical  Gazette^  vol.  xviii.  p.  777. 

^ See  “A  Letter  from  Mr.  Hey  concerning  the  effects  of  Fixed  Air  applied  by 
way  of  Clyster,”  in  Dr.  Priestley’s  Work,  vol.  ii.  p.  292. 

^ See  Dr.  Dobson’s  Medical  Commentary  on  Fixed  Air.  London,  1787,  p.  14. 
Dr.  Priestley  on  Air,  vol.  ii.  p.  375.  Dr.  Priestley’s  Experiments,  etc.,  on  the 
Different  Kinds  of  Air,  vol.  i.  p.  305. 

® See  Percival’s  Essays,  vol.  iii.  p.  237.  ® Priestley  on  Air,  vol.  i.  p.  305. 

^ Experiments  and  Observations  on  Different  Subjects,  p.  125. 


282 


LOCAL  ANAESTHESIA. 

i 

4.  Carbonic  acid  when  applied  to  the  surface  of  the  body — tlie 
skin  having  been  previously  removed — acts  as  a local  anaesthetic. 
A practice  which  probably  depends  for  its  utility  on  this  principle 
has  long  been  in  vogue.  The  old  yeast  poultice  {Catajplasma  cerevisice) 
exhales  from  its  surface  a quantity  of  carbonic  acid  gas ; and,  per- 
haps, the  beneficial  and  anodyne  effects  which  surgeons  formerly 
ascribed  to  it  in  the  treatment  of  irritable  and  sloughing  sores  was 
in  a great  degree  owing  to  the  carbonic  acid  eliminated  from  it 
serving  as  a local  anaesthetic  and  antiseptic.  The  constantly  recur- 
ring motion,  however,  of  points  in  the  surface  of  the  poultice,  from 
bubbles  of  the  gas  mechanically  raising  and  bursting  it,  does,  no 
doubt,  more  than  counteract,  in  some  instances,  any  sedative  effect 
that  is  derivable  from  the  topical  anaesthetic  application  of  the  car- 
bonic acid.  And  perhaps  far  simpler  means  could  be  easily  devised 
to  keep  an  open  and  painful  ulcer  or  wound  in  contact  with  a suffi- 
cient quantity  of  carbonic  acid.  Dr.  Percival  states  that  in  the 
application  of  pure  carbonic  acid  gas  to  a carcinomatous  sore,  the 
sanies  of  the  cancer  was  “ sweetened  by  it,  the  pain  mitigated,  and  a 
better  digestion  produced.”*  Dr.  Ewart  of  Bath  applied  it  locally 
in  two  cases  of  ulcerated  cancer  of  the  mamma.  In  the  first  of  these 
cases  the  ulcer,  which  was  nearly  five  inches  long,  three  inches  broad, 
and  about  two  inches  at  its  greatest  depth,  entirely,  though  tem- 
porarily, closed  up  and  cicatrised  in  three  months,  under  the  constant 
local  application  of  carbonic  acid  gas.  In  the  second  case  the  can- 
cerous ulcer  was  larger,  very  irregular  on  its  surface,  and  discharged 
a thin  mucous  foetid  matter.  It  filled  up  and  contracted  somewhat 
in  its  dimensions  under  the  use  of  carbonic  acid  ; and  at  the  date  of 
his  report,  viz.  at  the  end  of  two  months’  application  of  it.  Dr. 
Ewart  observes  that  at  least  the  gas  “ has  kept  a person  in  ease  and 
comfort,  who  for  so  great  a length  of  time  before  had  known  only 
agony  and  torture.”  “ What,”  he  elsewhere  observes,  “ strikes  us  in 
the  two  preceding  cases  with  the  greatest  astonishment,  is  the  almost 
instantaneous  relief  of  pain,  which  never  failed  to  follow  the  applica- 
tion of  the  gas.”'^  The  celebrated  Dr.  Ingenhouz,  who  saw  one  of 

’ Priestley’s  Work  on  Airs,  vol.  i.  p.  302.  Dr.  Percival  cites  also  the  following 
case  : — “A  physician  who  had  a very  painful  a])hthous  ulcer  at  the  point  of  his 
tongue,  found  great  relief,  when  other  remedies  failed,  from  the  application  of  fixed 
air  to  tlie  part  affected.  He  held  his  tongue  over  an  effervescing  mixture  of  potash 
and  vinegar,  and  as  the  pain  was  always  mitigated,  and  generally  removed  hy  this 
vaporisation,  he  repeated  it  whenever  the  anguish  arising  from  the  ulcer  was  more 
than  usually  severe.” 

2 Dr.  Histof  i/ of  two  cases  of  Cancer  treated  hy  Carbonic  Add.  liondon. 


CARBONIC  ACID. 


283 


these  cases,  in  which  a “large  cancerous  ulcer  of  the  breast”  had 
temporarily  cicatrised  under  the  local  application  of  carbonic  acid, 
and  then  re-opened,  states  that  still  the  ulcer  “gives  no  pain  when 
she  (the  patient)  applies  the  air.”^ 

The  application  of  the  carbonic  acid  gas  was,  however,  speedily 
recognised  as  not  capable  of  producing  a cure,  but  as  capable  of  pro- 
ducing alleviation  only.  “ The  public  prints,”  observes  the  celebrated 
French  chemist  Fourcroy,  “ contain  accounts  of  several  instances  of 
the  cure  of  cancer  made  in  England  by  the  application  of  the  car- 
bonic acid.  We  can,  nevertheless,  assert  that  this  means  has  been 
used  by  ourselves  and  others,  without  success,  several  times.  After 
the  first  application  the  cancerous  ulcer  exhibits  a more  favourable 
appearance  ; the  sanies  which  commonly  flows,  becomes  white,  con- 
sistent, and  laudable  ; the  flesh  assumes  a lively  colour ; but  these 
flattering  appearances  do  not  continue  ; the  ulcer  soon  returns  to  its 
former  state,  and  passes  through  the  usual  changes  with  unabated 
violence.”* 

In  reference  to  the  effects  of  carbonic  acid  upon  raw  surfaces  and 
wounds,  Dr.  Ingenhouz  rilentioned  to  Beddoes  the  following  experi- 
ment : — “ Blister  your  finger,  so  as  to  lay  bare  the  naked  and  sen- 
sible skin.  The  contact  of  air  will  produce  pain ; put  your  finger 
into  vital  air  (oxygen),  and  this  will  produce  more  pain ; introduce 
it  into  fixed  or  azotic  air  (carbonic  acid  or  nitrogen),  and  the  pain 
will  diminish  or  cease.”  In  relation  to  this  statement.  Dr.  Beddoes 
informs  us  that  he  made  the  following  experiments  on  three  different 
persons  : — First,  The  raised  epidermis  of  a blistered  finger,  after  all 
action  from  the  cantharides  had  ceased,  was  cut  away  in  carbonic 
acid  gas.  No  pain  was  felt.  Secondly,  A second  blister  being 
opened  in  common  air,  smarting  pain  came  on.  In  a bladder  of  fixed 
air,  this  pain  soon  went  off.  Thirdly,  After  opening  a third  blister, 
the  finger  was  instantly  plunged  into  oxygen.  It  felt  as  when  salt 
is  sprinkled  on  a cut.  In  carbonic  acid  gas  the  pain  in  two  minutes 
quite  subsided ; but  returned  when  the  denuded  skin  was  again 
exposed  to  the  atmosphere.^ 

If  there  be  no  source  of  fallacy  in  these  experiments,  they  cer- 

1795,  p.  48.  On  the  Medicinal  Effects  of  Factitious  Air,  part  iv.  By  T.  Beddoes, 
M.D.,  and  James  Watt,  Engineer.  Table  of  Cases,  p.  4. 

^ See  Part  iii.  of  the  Essay  oj  Beddoes  and  Watt,  p.  118  ; and  Ingenhouz’a 
Miscellanea,  etc.  1795. 

2 Fourcroy’s  Elements  of  Chemistry  and  Natural  History.  Prof.  John  Thom 
son’s  translation,  5th  edition,  vol.  i.  p.  395. 

^ On  the  Medicinal  Uses  of  Factitious  Airs,  pp.  43-45. 


284 


LOCAL  ANiESTHESIA. 


tainly  point  to  one  kind  of  important  improvement  in  the  treatment 
of  some  painful  burns,  wounds,  etc.  For  they  appear  to  me  to  sug- 
gest the  possibility  of  the  suffering  which  is  attendant  on  such 
injuries  being  controlled  and  cancelled  by  keeping  the  pained  parts 
in  contact  with  carbonic  acid,  or  with  some  other  gas  or  fluid,  capable 
of  acting  as  a local  anaesthetic.  If  the  reports  of  Ewart,  Beddoes, 
and  Fourcroy  are  correct,  we  ought  also,  indeed,  to  find  carbonic  acid 
an  excellent  application  even  as  far  as  the  mere  healing  and  cicatrisa- 
tion of  the  broken  surfaces  are  concerned. 

Note  on  painless  Extraction  of  Teeth. — T have  previously  (at  p.  260)  stated  that 
it  was  reported  that  M.  Pernot,  a dentist  at  Limoges,  in  France,  had  the  secret  of 
extracting  teeth  wdth  little  or  no  pain,  in  consequence  of  previously  applying  some 
obtunding  agent  to  the  gums.  More  recently,  I have  been  informed  by  several 
persons,  some  of  them  medical  men  who  had  practised  at  Hong-Kong,  etc.,  that  the 
extraction  of  teeth  is  sometimes  performed  in  China  without  pain.  The  alleged 
secret  of  thus  annulling  the  pain  incident  on  tooth-extraction  seems  to  be  possessed 
by  a particular  guild  of  dentists  in  the  Celestial  Empire.  They  are  said  to  apply 
locally  the  anodyne,  and  to  be  able  to  pull  out  the  tooth  with  very  little  force  or 
pain  some  hours  subsequently.  The  substance  employed  is  generally  reputed  to 
be  extracted  from  the  head  of  a fish  ; and,  if  so,  jnay  probably  be  some  form  of 
phosphoric  acid.  Is  it  possible  that  any  form  of  this  acid  can  soften  the  tooth,  or 
its  bony  socket,  as  acids  generally  soften  bone,  permitting  its  removal  without 
pain,  while  the  surrounding  soft  textures  remain  uninjured? 


CARBONIC  ACID. 


285 


CHAPTER  VI. 

PARTS  AND  SURFACES  TO  WHICH  CARBONIC  ACID  MAY  BE  APPLIED. 

Edinburgh^  Ajpril  1858. 

In  the  preceding  remarks  we  have  seen  that  carbonic  acid  has 
been  formerly  applied  in  some  form  as  a local  anodyne  or  anaesthetic 
to  various  parts  or  surfaces — as, 

1.  The  vagina  and  uterus. 

2.  The  rectum  and  lower  end  of  the  intestinal  canal 

3.  The  interior  of  the  stomach. 

4.  The  surface  of  the  tongue. 

5.  The  ulcerated  surface  of  the  skin,  mamma,  etc. 

There  are  other  surfaces  and  structures  upon  which  I have  found 
the  local  application  of  carbonic  acid  act  sometimes  with  remarkable 
success  as  a local  anodyne  or  anaesthetic — as, 

6.  The  Mucous  Surface  of  the  Eye, 

I have  used  it  principally  in  cases  of  photophobia  and  hyper- 
aesthesia  of  the  eye  connected  with  scrofulous  ophthalmia,  where 
often  it  gives  speedy  and  marked  relief.  A few  drops  of  chloroform 
evaporated  from  the  palm  of  the  patient’s  hand,  and  held  near  the 
eye,  will  generally,  in  the  same  way,  allow  a photophobic  eye  to 
open,  and  form  an  application  far  more  easily  used,  and  as  curative, 
as  any  medicated  liquids  or  collyria  dropped  into  the  eye. 

7.  The  Mucous  Surface  of  the  Bladder. 

I have  already  mentioned  a case,  in  which,  after  many  modes  of 
treatment  had  failed,  the  injection  of  carbonic  acid  gas  into  the 
vaginal  canal  several  times  a-day  at  once  produced  relief,  and  ulti- 
mately effected  a perfect  cure.  I lately  heard  of  this  patient — a 
Canadian — remaining  perfectly  well. 

Before  1732  the  celebrated  Dr.  Hales  had  described  to  the 
Royal  Society,  the  injection,  without  injury,  into  the  bladder  of  the 
dog,  of  a menstruum,  consisting,  to  use  the  words  of  Dr.  Willis,  “ of 


286 


LOCAL  ANESTHESIA. 


a mixed  solution  of  bicarbonate  of  potash,  sulphate  of  potass  and 
carbonic  acid  in  water.”  ^ In  consequence  of  his  attention  being 
directed  to  the  subject  by  my  paper, ^ as  analysed  by  M.  Follin  in  the 
Archives  Generales  de  Medecine,  M.  Broca  injected  carbonic  acid  into 
the  bladder,  and  published  some  of  the  successful  results  which  he 
obtained  in  the  Moniteur  des  Hopitanx  for  August  1857.  More 
lately  (March  1858),  Dr.  Johns  has  brought  the  same  method  of 
treatment  under  the  notice  of  the  profession  in  Dublin.  Perhaps  I 
will  be  excused  for  remarking  that  there  is  no  class  of  ailments  more 
distressing,  or  more  difficult  to  treat,  than  the  different  forms  of 
morbid  irritability  of  the  bladder,  and  in  the  management  of  the 
affections  I have  obtained  far  more  favourable  results  from  the  local 
application  and  injection  of  carbonic  acid  than  I could  have 
ventured  to  anticipate.  The  freedom  and  safety  with  which  car- 
bonic acid  and  some  other  medicinal  fluids  and  liquids  may  be 
injected  into  the  cavity  of  the  bladder  will  probably  be  ere  long 
more  fully  acknowledged  by  the  profession,  and  great  practical 
advantage  taken  of  this  fact  in  the  treatment  of  dysuria  and  other 
morbid  states  of  the  bladder. 

In  one  of  his  letters  to  Dr.  Priestley,  dated  1775,  Dr.  Percival 
states  that  he  had  found  “ by  repeated  trials  that  calculi  are  soluble 
in  water  impregnated  with  fixed  air,”  or  carbonic  acid  ; and,  he  adds, 
that  it  had  acted  in  his  experiments  “ upon  every  calculus  which 
was  suspended  in  it.”  He  and  Dr.  Home  hoped  that  carbonic  acid 
given  in  effervescing  drinks  by  the  mouth  would  reach  the  bladder 
as  carbonic  acid,  and  there  act  as  a lithontriptic  upon  the  contained 
calculus.  But  if  carbonic  acid  can  act  upon  some  forms  of  urinary 
calculus  as  a dissolvent,  we  know  that  it  can  be  introduced  freely 
and  continuously  by  a double  catheter  into  the  bladder.  In  a most 
interesting  case  reported  by  Sir  Benjamin  Brodie,  the  repeated  in- 
jection of  a very  weak  solution  of  nitric  acid  into  the  bladder 
successfully  dissolved  and  removed  a phosphatic  calculus ; and  he 
has  found  the  same  solution  relieve  chronic  inflammation  of  the 
lining  membrane  of  the  bladder.  On  the  contrary,  it  has  been 
further  long  known  that  a calculus,  probably  of  lithic  acid,  was 
broken  down  and  removed  by  Professor  Eutherford  and  Mr.  Butter 
by  free  and  frequent  injections  of  tepid  lime-water  into  the  urinary 
bladder.  Surely  the  time  is  not  far  distant  when  a higher  chemistry 
will  thus  enable  us  to  remove  some  calculi  at  least  without  the 
horrid  necessity  of  the  knife  or  lithontrite. 

^ Urinary  Diseases,  p.  330. 


2 Supra,  Chap.  V. 


CAKBONIC  ACID. 


287 


• 8.  The  Mucous  Surface  of  the  Trachea  and  Lungs. 

In  forming  carbonic  acid  for  application  as  a local  ana3sthetic,  I 
have  generally  placed  together  six  drachms  of  crystallised  tartaric 
acid  and  eight  drachms  of  bicarbonate  of  soda  in  a common  wine- 
bottle,  added  six  or  seven  ounces  of  water,  and  allowed  the  gas  to 
escape  through  a perforated  cork,  and  attached  a caoutchouc  tube 
to  the  part  to  which  it  was  applied.  In  a considerable  number  of 
instances  of  chronic  bronchitis,  asthma,  irritable  cough,  etc.,  I have 
directed  the  patient  to  breathe  the  carbonic  acid,  which  escaped 
from  the  above  mixture,  by  placing  the  end  of  the  tube  in  his 
mouth.  In  a large  proportion  of  these  cases  the  relief  obtained  has 
been  most  striking ; and  in  several  chronic  instances  the  benefit  has 
been  at  once  both  speedy  and  permanent.  The  quantity  of  gas  thus 
set  loose  and  inhaled  is  not  so  very  great  in  quantity  as  the  rapid 
and  continuous  rush  of  it  into  the  patient’s  mouth  would  lead  a 
person  to  suppose ; and  it  acts,  I believe,  in  these  cases  as  a local 
sedative  or  aiicesthetic  applied  to  the  whole  lining  pulmonary  mem- 
brane, like  the  smoke  of  stramonium,  or  the  vapour  of  chloroform. 
The  common  idea  that  spasm  of  the  glottis  will  come  on  whenever 
carbonic  acid  is  breathed  in  any  considerable  quantity  will  be  found 
quite  incorrect.  I will  perhaps  take  an  early  opportunity  of  stating 
at  length  the  unexpected  results  of  this  practice ; one  wdiich,  even 
after  all,  is,  I find,  not  quite  novel,  as,  in  the  last  century.  Dr. 
Percival  tried  in  phthisis  pulmonalis  the  inspiration  of  fixed  air  or 
carbonic  acid  “ by  inhaling  the  steams  of  an  effervescing  mixture  of 
chalk  and  vinegar,  or  of  vinegar  and  potash,”  and  Drs.  Lettsom, 
Withering,  and  Hulnie,  tried  a similar  method. 

9.  To  External  Wounds  and  Burns, 

Seeing,  1st,  the  great  and  speedy  relief  to  pain  in  cancerous  and 
other  sores  obtained  through  the  local  application  of  carbonic  acid  by 
Ewart,  Ingenhouz ; and  2d,  the  tendency  to  cicatrisation  observed 
even  in  some  malignant  ulcers  when  carbonic  acid  was  kept  in  con- 
tact with  them,  I ventured  in  my  paper  on  the  subject  to  suggest 
the  topical  employment  of  carbonic  acid  to  surgical  wounds  and 
burns,  as  at  once  both  relieving  suffering,  and  being  one  of  the  best 
means  for  producing  rapid  healing  and  cicatrisation.  If  found 
successful,  it  would  not  be  difficult  to  devise  simple  means  of 
applying  it  as  a constant  dressing.  But  no  sufficient  experiments, 
so  far  as  I am  aware,  have  been  as  yet  made  upon  the  matter. 


288 


LOCAL  ANESTHESIA. 


In  the  preceding  remarks  I have  scarcely  referred,  except  inci- 
dentally, to  the  question  of  the  utility  of  carbonic  acid  as  a local 
anaesthetic  when  applied  to  various  mucous  surfaces  and  exposed 
external  structures.  Let  me  only  in  the  meantime  add,  that  all  my 
subsequent  experience  has  in  my  opinion  more  than  confirmed  the 
views  which  I ventured  to  publish  tw’o  or  three  years  ago  with  re- 
gard to  its  practical  utility  and  efficiency  as  a local  sedative  or 
anodyne  agent.  The  late  observations  of  Drs.  Churchill,  Johns, 
etc.,  in  our  own  country,  and  of  Follin,  Broca,  Bernard,  etc.,  in 
France,  all  tend  further  to  prove  and  establish  the  advantages  to  be 
often  obtained  in  practice  from  the  employment  of  this  therapeutic 
agent  as  a topical  ancesthetic. 


HOSPITALISM. 


CHAPTER  I. 

COUNTRY  AMPUTATION  STATISTICS. 

1.  Preliminary  Eemarks. 

Perhaps  one  of  the  most  weighty  and  momentous  questions  to 
which,  at  the  present  day,  the  physician,  the  surgeon,  and  the 
accoucheur  can  direct  his  attention,  is  the  proper  reconstruction  and 
arrangement  of  our  hospitals.  The  vast  importance  of  the  subject 
depends  upon  this  point,  that  it  involves  the  study  and  rectification 
of  influences  that  seem  at  present  to  set  utterly  at  defiance  all  the 
proudest  advances  of  practical  medicine.  When  the  two  largest 
hospitals  in  Scotland — viz.  the  Infirmaries  of  Edinburgh  and  Glas- 
gow— were  opened  in  the  last  century,  the  buildings  of  which  they 
then  consisted  were  new  and  fresh,  and  comparatively  small.  In 
the  Edinburgh  Infirmary,  out  of  the  first  99  cases  in  which  the 
limbs  were  amputated,  8 of  the  patients  died,  or  1 in  12.  Out  of 
the  first  30  amputations  for  disease  in  the  Glasgow  Infirmary,  1 
patient  only  died.  At  the  present  day,  in  these  now  greatly- 
enlarged  and  palatial  hospitals,  the  mortality  from  the  same  opera- 
tions has  latterly  become  higher  than  1 in  every  3 operated  upon. 
But  surely  during  the  last  fifty  or  a hundred  years  surgery  has  made 
much  signal  and  striking  progress  in  various  ways  and  in  various 
directions.  Amputation,  for  instance,  as  an  operation,  has,  like 
many  other  operations,  been  mightily  improved  in  the  modes  of  its 
performance,  in  the  modes  of  arresting  the  attendant  hemorrhage, 
in  the  modes  of  dressing  the  stumps,  etc. ; but  still  in  these  hospi- 
tals the  mortality  from  limb-amputations  has,  since  the  last  century, 
become  increased  instead  of  diminished.  This  increase  is  traceable, 
I believe,  chiefly  or  entirely  to  our  system  of  huge  and  colossal 
hospital  edifices,  and  to  the  hygienic  evils  which  that  system  has 


290 


HOSPITALISM. 


hitherto  been  made  to  involve.  If  it  be  so,  then  that  system  coun- 
teracts and  cancels  all  the  advances  and  improvements  which  modern 
surgical  and  medical  science  has  evoked ; and  we  cannot,  in  my 
opinion,  hope  for  adequate  and  commensurate  progress  in  the  public 
practice  of  the  healing  art,  till  our  system  of  hospitalism  is  more  or 
less  changed  and  revolutionised. 

Above  twenty  years  ago,  in  speaking  of  the  effects  and  evils  of 
our  large  hospitals — as  these  hospitals  are  at  present  constructed — 
I took  occasion  to  remark  : “ There  are  few  or  no  circumstances 
which  would  contribute  more  to  save  surgical  and  obstetric  patients 
from  phlebitic  and  other  analogous  disorders,  than  a total  change 
in  the  present  system  of  hospital  practice.  I have  often  stated  and 
taught,  that  if  our  present  medical,  surgical,  and  obstetric  hospitals 
were  changed  from  being  crowded  palaces, — with  a layer  of  sick  in 
each  flat, — into  villages  or  cottages,  with  one,  or  at  most  two,  patients 
in  each  room,  a great  saving  of  human  life  would  be  effected ; and 
if  the  village  were  constructed  of  iron  (as  is  now  sometimics  done 
for  other  purposes)  instead  of  brick  or  stone,  it  could  be  taken  down 
and  rebuilt  every  few  years — a matter  apparently  of  much  moment 
in  hospital  hygiene.  Besides,  the  value  of  the  material  would  not 
greatly  deteriorate  from  use ; the  principal  outlay  would  be  in  the 
first  cost  of  it.  It  could  be  erected  in  any  vacant  space  or  spaces 
of  ground,  within  or  around  a city,  that  chanced  to  be  unoccupied ; 
and  in  cases  of  epidemics,  the  accommodation  could  always  be  at 
once  and  readily  increased.”  ^ 

Since  the  date  mentioned,  I have  conversed  on  many  occasions 
with  many  medical  men  upon  this  subject.  I have  found,  however, 
that  to  most  professional  minds  it  seemed  to  be  altogether  a kind 
of  medical  heresy  to  doubt  that  our  numerous  and  splendid  hospitals 
for  the  sick  poor  could  by  any  possibility  be  aught  other  than  institu- 
tions as  beneficial  in  their  practical  results  as  they  were  benevolent 
in  their  practical  objects.  When  acting  in  1867,  at  Belfast,  as  Presi- 
dent of  the  Public  Health  section  of  the  National  Association  for 
the  Promotion  of  Social  Science,  I spoke  of  the  subject  of  hospi- 
talism at  some  length  in  my  inaugural  address,  and  propounded  the 
questiohs,  “ To  what  extent  are  hospitals,  as  in  general  at  present 
constituted,  banes  or  blessings '?  and  how  can  they  be  changed  so  as 
to  convert  them  from  the  former  to  the  latter  1”  I concluded  my 
remarks  on  this  point  by  again  suggesting  publicly,  that  to  render 
our  hospitals  as  healthy  and  useful  as  possible,  and  in  order  to 
^ Edinburgh  Montldy  Journal  of  Medical  Science^  November  1848,  p.  328. 


COUNTRY  AMPUTATION  STATISTICS. 


291 


acquire  sufficient  space  and  air  and  isolation  for  their  sick  inmates, 
they  should  be  changed  “ from  wards  into  rooms,  from  stately 
mansions  into  simple  cottages,  from  stone  and  marble  palaces  into 
wooden,  or  brick,  or  iron  villages.”  On  the  same  occasion,  after 
speaking  of  the  relative  treatment  of  some  medical  diseases,  as 
fevers,  etc.,  in  and  out  of  hospitals,  and  after  showing  (chiefly  from 
the  large  statistics  of  M.  Lefort)  that,  as  a general  rule,  parturient 
women  recovered  in  a much  larger  proportion  when  delivered  in 
their  own  homes  than  when  delivered  in  lying-in  hospitals,  I pro- 
ceeded to  ask,  “ In  regard  to  surgical  patients  in  hospitals,  as  com- 
pared with  surgical  patients  at  home,  does  the  same  law  hold  good 
as  in  respect  to  obstetric  patients  'i  At  the  present  time,  medical 
science  is,  I believe,  in  want  of  any  sufficient  data  to  determine  the 
question.  The  general  mortality  in  hospitals  after  operations  is 
confessedly  very  great,  far  greater  than  was  believed  a quarter  or 
half  a century  ago,  when  no  sufficient  statistics  had  been  collected 
on  the  matter.  The  man  laid  on  an  operating-table  in  one  of  our 
surgical  hospitals  is  exposed  to  more  chances  of  death  than  the 
English  soldier  on  the  field  of  Waterloo.  Some  authors  have  col- 
lected, on  a large  scale,  the  statistical  results  of  some  special  opera- 
tions, and  particularly  of  amputation  of  the  limbs.  Out  of  1656 
cases  of  amputation  performed  in  the  hospitals  of  Paris,  and  col- 
lected by  MM.  Malgaigne  and  Trelat,  803  of  the  patients  died,  or 
nearly  1 in  every  2.^  Dr.  Fenwick  has  collected  together  from 
various  sources  4937  cases  of  amputations  of  the  limbs.  Of  these, 
1562  died,  or  nearly  1 in  every  3 or  4.  ‘The  assertion,’  observes 
Dr.  Fenwick,  ‘ that  one  person  out  of  every  three  who  suffers  an 
amputation  perishes,  would  have  been  repudiated  a few  years  ago 
as  a libel  upon  the  profession,  and  yet  such  is  the  rate  of  mortality 
observed  in  nearly  5000  cases.’  Are  the  results  of  amputation  in 

^ M.  Trelat’s  list  contains,  besides  the  major  amputations  of  the  limbs,  minor 
amputations  also  of  the  hand  and  foot.  Dr.  Bristowe  and  Mr.  Holmes  of  Lon- 
don, in  visiting  the  Parisian  hospitals  in  order  to  draw  up  a report  upon  them  for 
the  medical  officer  of  the  Privy  Council  (Mr.  Simon),  obtained  from  the  goveni- 
ment  official  archives  the  results  of  the  major  amputations  of  the  limbs — that  is, 
of  the  thigh,  leg,  arm,  and  forearm — during  the  year  1861  in  all  the  Parisian 
hospitals  taken  as  a whole.  The  mortality  among  those  operated  upon  was  as 
high  as  1 in  1^  ; or  3 out  of  every  5 died.  We  shall  afterwards  see  that  this  is 
nearly  double  the  death-rate  which  attends  upon  the  same  operations  in  our 
large  and  metropolitan  British  hospitals,  in  which  the  mortality  is  fully  1 in  3 ; 
while,  as  Mr.  Simon  points  out,  in  reference  to  our  smaller  and  rural  Britisli 
hospitals,  the  special  death-rate  from  amputations  “in  the  London  hospitals  is 
half  as  high  again  as  in  the  country  hospitals.” 


292 


HOSPITALISM. 


dispensary,  private,  or  country  practice,  as  deplorable  ? Adequate 
data  on  the  matter  have  not  been  collected.  Certainly  the  general 
belief  of  the  profession  is,  that  in  country  practice  amputations  are 
not  so  frightfully  fatal.”  * 

I have  often  thought  of  trying  to  collect  the  data  referred  to  in 
the  preceding  sentences,  and  as  often  delayed  the  task,  as  being 
apparently  more  a duty  pertaining  to  others.  Circumstances,  how- 
ever, connected  with  the  rebuilding  of  the  Edinburgh  Hospital,  have 
lately  induced  me  to  attempt  this  statistical  inquiry ; and  the  object 
of  the  next  chapter  is  to  state  the  results. 

2.  Mortality  of  the  Major  Amputations  of  the  Limbs  in 
Private  Country  and  Provincial  Practice.* 

With  the  hope  of  collecting  sufficient  data  to  approach,  if  not 
to  determine,  the  rate  of  mortality  generally  attendant  upon  ampu- 

^ Transactions  of  Social  Science  Association  for  1867,  p.  115. 

2 Other  Operations  used  as  Standards  of  Comparison. — Several  operations  have 
heen  suggested  and  employed  as  forming  in  their  results  statistical  criteria  or 
tests  of  tlie  relative  salubrity  and  success  of  surgery  in  different  hospitals,  and  in 
different  practices,  and  under  different  conditions.  Those  operations  that  have 
been  chiefly  used  for  this  purpose  are, — Lithotomy,  Herniotomy,  and  Amputation 
of  the  Limbs.  The  two  first  are  not  fitted  to  form  tests  or  standards,  in  such  an 
inquiry  as  the  present,  between  the  results  of  hospital  practice  and  of  private 
country  practice.  For  it  would  be  impossible  to  procure  from  the  country  a 
sufficient  number  of  cases  of  lithotomy,  for  example,  to  make  the  required  com- 
parison, as  that  operation  is  rarely  performed  by  the  country  practitioner  ; and 
the  patients,  being  usually  quite  able  to  move  and  travel,  usually  place  themselves 
under  the  care  of  skilled  hospital  or  metropolitan  surgeons.  Herniotomy,  again, 
is  an  operation  in  the  successful  performance  and  result  of  which  much  depends 
upon  the  attainment  of  the  proper  period  of  operating,  as  well  as  upon  the  surgi- 
cal dexterity  and  delicacy  with  which  the  operation  itself  is  performed.  Hence 
it  is  not  very  capable  of  being  used  in  any  comparison  between  its  relative 
mortality  in  the  hands  of  a rural  practitioner  and  in  the  hands  of  an  accomplished 
hospital  surgeon.  It  would  be,  on  the  large  scale,  a test  rather  of  the  operative 
.skill  of  the  practitioner  than  of  the  influence  upon  the  patients  of  external 
cii'cumstances  and  surroundings  that  are  independent  of  the  mode  in  which  the 
operation  is  conducted.  But  in  this  last  respect,  and  for  the  purpose  of  com- 
paring the  results  of  surgical  operations  in  country  and  in  hospital  practice,  the 
major  amputations  of  the  limbs  undoubtedly  form  the  best,  if  not  the  only 
adequate,  standard.  The  operation  itself  of  amputation,  formidable  as  it  is  in  its 
character, — since,  generally,  it  involves  the  loss  of  a limb  to  save  the  loss  of  a 
life, — is  not  a proceeding  attended  with  much  surgical  difficulty,  or  requiring 
much  surgical  skill,  so  that  it  can  be  done  readily  in  the  country  as  well  as  in 
the  hospital  ; it  is  resorted  to  for  the  same  classes  of  injuries  and  for  the  same 
classes  of  diseases  in  the  one  locality  as  in  the  other  ; and,  in  rural  as  well  as  in 
hospital  practice,  it  is  performed  so  frecpiently  as  to  afford  sufficient  cumulative 
masses  of  data  for  correct  statistical  deductions. 


COUNTRY  AMPUTATION  STATISTICS. 


293 


tations  of  the  thigh,  leg,  arm,  and  forearm,  when  performed  in 
private  country  and  provincial  practice,  I addressed  the  following 
application — along  with  the  accompanying  form  of  schedule — to 
numerous  medical  gentlemen  practising  in  England  and  Scotland  : — 

“The  relative  success  of  the  graver  operations  in  surgery,  as  performed,  first, 
in  hospital  practice,  and,  secondly,  in  private  practice,  is  at  x>resent  attracting 
much  attention  here  and  elsewhere. 

“ There  is  reason  to  believe  that  some  of  the  greater  operations — as  the  various 
amputations  of  the  limbs — are  attended  with  less  mortality  in  private  and  in 
country  practice  than  in  hosjiital  practice. 

“Already  there  have  been  published  by  various  authors  amjde  statistics  of 
the  results  of  amputations  of  the  limbs  from  many  different  surgical  hospitals. 
But  hitherto  there  has  not  been  made  any  collection  showing  the  results  of  the 
same  amputations,  or  of  any  similar  o^jerations,  in  x^rivate,  and  particularly  in 
country  practice. 

“With  a view  of  making  the  comparison  in  question,  I should  feel  deeply 
obliged  if  you  would  kindly  fill  up  the  included  form  with  the  results  of  all  the 
amputations  which  you  may  have  had  in  your  own  practice.  However  few  may 
be  the  am x>u tations  of  the  limbs  which  you  have  performed,  the  notification  in 
the  table  of  their  nature  and  their  results  (whether  the  case  or  cases  ended  in 
recovery  or  in  death),  will  be  regarded  as  a very  great  favour. 

“ An  accumulation  of  several  hundred  returns — even  though  the  numbers  in 
individual  practice  may  not  exceed  two  or  three — will  go  far,  it  is  believed,  to 
throw  much  light  on  the  momentous  subject  of  the  x^resent  inquiry. 

“ It  would  be  an  additional  favour  if  you  could  inform  me  whether  your  cases 
of  amputation  were  in  persons  belonging  to  (1)  the  upper,  (2)  the  middle,  or  (3) 
the  lower  classes  ; and  whether  their  status  in  society,  or  the  character  of  their 
habitations,  appeared  to  influence  the  results.  It  is  thought  by  many  that,  after 
amputations  and  similar  great  operations,  the  poor  recover  in  a greater  proportion 
in  their  own  homes  than  they  do  in  the  wards  of  our  very  best  hospitals.” 

The  included  schedule  was  in  the  following  form : — 


EesuUs  of  Amputation  of  the  Limbs  in  Private  Practice. 


Seat  of  the  Amputations. 

Primary,  or  for  Injury. 

Secondarj’’,  or  for  Disease. 

Number  of 
Cases. 

Number  of 
Deaths. 

Number  of 
Cases. 

Number  of 
Deaths. 

Amputation  of  Thigh  . 
Amputation  of  Leg 
Amputation  of  Arm 
Amputation  of  Forearm  . 

Total  . . 

Signature, 
P^esidence, . 
Date, 


The  Uvo  blank  pages  of  the  schedule  which  followed  wefre 


294 


HOSPITALISM. 


lieaded  “ Remarks,”  for  the  purpose  of  eliciting  observations  from 
the  gentlemen  filling  up  the  returns. 

In  selecting  the  practitioners  to  whom  the  application  and 
schedules  were  sent,  I avoided,  as  far  as  possible,  including  in  the 
list  any  members  of  the  profession  residing  in  our  large  hospital 
cities  and  towns,  as  my  object  was  to  obtain  the  returns  princijmlly 
or  entirely  from  country  and  provincial  professional  men.  For 
example,  with  this  view  I did  not  apply  in  Scotland  to  any  practi- 
tioners in  Edinburgh,  Glasgow,  Aberdeen,  Dundee,  Dumfries,  etc. 
In  England  the  application  was  chiefly  made  to  practitioners  con- 
nected with  the  Poor  Law  service  ; but  others  were  included,  who 
appeared  likely  to  be  able  to  furnish  the  required  returns. 

Some  did  not  return  the  schedule ; others  returned  it  blank ; 
and,  in  doing  so,  they  usuall}''  stated  either  that  no  cases  of  ampu- 
tation had  occurred  in  their  practice,  or  that  they  were  so  near 
some  hospital  or  another  as  to  have  been  always  in  the  habit  of 
forwarding  there  any  such  patients  as  required  amputation. 

Several  of  the  returned  schedules  contained  cases  of  amputations 
of  the  limbs,  performed  not  by  the  practitioners  who  filled  in  the 
schedule,  but  by  their  friends.  These  returns  I have  not  of  course 
used,  except  when  there  were  data  given  that  enabled  the  two 
classes  of  cases  to  be  separated ; because  my  application  was,  in 
each  instance,  for  all  the  cases  of  limb-amputation  performed  by  the 
gentleman  himself  who  returned  the  schedule  ; and  not  for  such  as 
he  might  have  seen  or  known  to  have  been  done  by  others,  as  such 
reports  of  these  last  did  not  include  and  show  the  results  of  all  the 
cases  operated  upon  by  those  other  practitioners. 

Two  or  three  instances  have  been  reported  in  the  schedules 
where  the  amputation  was  performed  in  the  country,  and  the 
patients  forthwith  sent  on  into  city  hospitals.  As  these  hybrid 
amputations  were  neither  truly  hospital,  nor  truly  country  cases,  I 
have  omitted  them  altogether  from  the  Table.  One  of  these  cases 
was,  during  their  hospital  residence,  attacked  with  erysipelas,  and 
another  with  gangrene. 

A number  of  gentlemen  have  informed  me  that  they  have 
repeatedly  performed  amputations,  but  have  kept  no  such  record  of 
them  as  to  be  able  to  report  them  with  statistical  accuracy.  Some 
who  have  often  operated,  while  unaware  of  the  extent  of  their 


COUNTRY  AMPUTATION  STATISTICS. 


295 


numbers,  have  assured  me  that  they  recollected  all  their  fatal  cases, 
and  that  their  number  was  comparatively  small.  Thus,  in  one  of 
the  last  unfilled  schedules  which  I have  received.  Dr.  Itedwood  of 
lihymney,  practising  in  an  iron-work  district  in  Monmouthshire, 
writes  me  as  follows  : — “ Unfortunately  I have  kept  no  account  of 
my  cases  of  amputation  of  thighs,  legs,  arms,  and  forearms.  I 
believe  I have  had  between  forty  and  fifty ; certainly  more  than 
forty.  They  all  recovered  except  t>vo,  that  died  from  the  shock  of 
the  accident ; one  on  the  table,  and  the  other  in  a few  hours  after 
operating.  My  successful  amputations  include  three  at  the  shoulder- 
joint,  and  one  of  both  legs.”  In  compound  fractures  (he  adds), 
“ where  there  is  tissue  left  that  will  continue  the  circulation  below 
the  seat  of  injury,  save  the  limb.  Assistants  fresh  from  the 
hospitals  are  often  astonished  at  what  is  attempted  and  effected  in 
this  way.  . . Some  of  the  patients  are  rather  hard-drinking 

men.” 

In  the  following  Table,  No.  I,  I have  entered  all  the  available 
data  that  have  been  furnished  to  me  in  answer  to  my  inquiries, 
whether  they  were  good,  bad,  or  indifferent.  In  the  first  part  the 
returns  are  almost  entirely  Scottish ; the  other  portions  are  partly 
from  England  and  Wales,  and  partly  from  Scotland.  The  numeral 
in  the  first  row  of  the  Table  is  the  number  attached  to  each  schedule 
as  it  was  returned  and  entered,  so  as  to  facilitate  reference  to  it,  etc. 


75 


296 


HOSPITALISM. 


Table  I. — Op  Amputations  and  their  Kesults — Primary  or  for  Injury, 
AND  Secondary  or  for  Disease — of  the  Thigh,  Leg,  Arm,  and 
Forearm,  performed  in  Private  Practice  by  Country  and  Provin- 
cial Practitioners  ; Amputations  through  the  Joints  not  included. 


Primary. 


52;  73 


1 

2 

3 

4 

5 

6 

7 

8 
9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 
21 
22 

23 

24 

25 

26 

27 

28 

29 

30 

31 

32 

33 

34 

35 

36 

37 

38 

39 

40 

41 

42 


Tliish. 


Secondary. 


Le 

Arm. 

Eorearm. 

Thigh. 

Le 

O* 

Arm. 

Forearm. 

No.  of 
Cases. 

Deaths. 

No.  of 
Cases. 

Deaths. 

No.  of 
Cases. 

Deaths. 

No.  of 

Cases. 

Deaths. 

No.  of 

Cases. 

Deaths. 

No.  of 

Cases. 

j Deaths. 

No,  of 

Cases. 

Deaths. 

2 

0 

1 

0 

1 

0 

2 

0 

1 

0 

. . 

1 

0 

1 

0 

1 

0 

1 

0 

1 

0 

4 

0 

2 

0 

2 

0 

3 

0 

1 

0 

2 

0 

2 

1 

2 

0 

1 

1 

2 

0 

1 

0 

1 

0 

1 

0 

. . 

. . 

2 

0 

1 

0 

1 

1 

1 

1 

1 

0 

1 

0 

2 

0 

1 

0 

1 

0 

2 

0 

1 

0 

1 

0 

1 

0 

3 

0 

4 

1 

2 

0 

2 

0 

. . 

*1 

0 

1 

1 

1 

0 

1 

0 

1 

0 

5 

0 

. . 

3 

0 

2 

1 

1 

0 

1 

0 

3 

0 

1 

0 

4 

0 

1 

0 

1 

0 

1 

0 

2 

0 

. . 

2 

1 

2 

0 

1 

0 

. . 

1 

0 

1 

0 

1 

0 

2 

1 

. , 

, . 

1 

0 

1 

0 

1 

0 

5 

0 

4 

0 

3 

0 

4 

0 

1 

0 

2 

0 

1 

0 

5 

0 

1 

1 

1 

0 

1 

0 

1 

0 

1 

0 

1 

0 

2 

0 

2 

0 

2 

0 

2 

0 

2 

0 

1 

0 

1 

0 

. . 

. . 

1 

0 

1 

0 

1 

0 

1 

0 

1 

0 

1 

0 

• • 

COUNTRY  AMPUTATION  STATISTICS. 


297 


No.  of  the  1 

Schedules. 

Pm  MARY. 

Secondary. 

Thigh, 

Leg. 

Arm. 

Forearm. 

Thigh. 

Leg. 

Arm. 

No.  of 
Cases. 

Deaths. 

No.  of 
Cases. 

Deaths. 

O S 
,<5  S 

Deaths. 

No.  of 

Cases. 

Deaths. 

No.  of 

Cases. 

Deaths. 

No.  of 

Cases. 

Deaths. 

No.  of 

Cases. 

Deaths. 

43 

1 

0 

2 

0 

1 

0 

5 

0 

5 

1 

1 

0 

44 

4 

1 

16 

2 

13 

1 

13 

0 

12 

0 

8 

0 

45 

1 

1 

1 

0 

46 

1 

0 

1 

0 

47 

1 

0 

1 

0 

48 

1 

0 

49 

1 

0 

5 

0 

3 

0 

1 

1 

50 

5 

1 

6 

0 

4 

0 

3 

0 

51 

2 

0 

1 

0 

52 

1 

1 

1 

0 

8 

0 

53 

, , 

1 

0 

1 

0 

54 

1 

0 

1 

0 

1 

0 

55 

2 

0 

1 

0 

1 

0 

1 

1 

56 

, , 

1 

1 

1 

0 

1 

0 

57 

2 

0 

1 

0 

58 

1 

0 

, . 

1 

0 

1 

1 

59 

3 

0 

1 

0 

2 

0 

1 

0 

60 

1 

0 

1 

0 

61 

5 

1 

4 

0 

2 

1 

1 

1 

4 

0 

.. 

62 

1 

0 

63 

1 

0 

64 

1 

0 

2 

0 

65 

1 

0 

1 

0 

Y 

*6 

1 

0 

66 

1 

0 

67 

, . 

1 

0 

, . 

. . 

1 

0 

1 

0 

68 

3 

1 

4 

1 

4 

0 

3 

0 

69 

1 

0 

1 

0 

1 

0 

70 

. . 

. . 

1 

0 

2 

0 

71 

2 

1 

3 

0 

4 

0 

3 

0 

4 

1 

2 

0 

1 

0 

72 

1 

0 

73 

1 

0 

1 

0 

1 

1 

74 

1 

1 

75 

1 

0 

1 

0 

1 

0 ; 

3 

0 

76 

« . 

1 

0 

1 

1 

2 

0 

77 

2 

0 

..  1 

2 

0 

78 

1 

0 

79 

2 

0 

4 

2 

1 

0 

80 

1 

0 

2 

0 

1 

0 

2 

.0 

1 

1 

81 

1 

0 1 

• o 

1 

1 

82 

2 

1 

83 

1 

0 

1 

0 

3 

0 

6 

2 

6 

1 

2 

0 

84 

1 

0 

85 

. . 

2 

0 

1 

0 

1 

0 

1 

0 

2 

0 

86 

1 

0 

2 

0 

2 

1 

87 

1 

6 

1 

6 

2 

0 

1 

1 

88 

1 

0 

89 

3 

0 

6 

1 

3 

0 

3 

0 

90 

1 

1 

7 

0 

1 

0 

2 

0 

2 

0 

91 

2 

0 

92 

11 

0 

4' 

0 

3 

0 

4 

0 

1 

0 

93 

2 

0 

Forearm 


Deaths. 


298 


HOSPITALISM. 


No.  of  the 
Schedules. 

Pkimary. 

Secondary. 

Thigh. 

Leg. 

Arm. 

Forearm. 

Tliigh. 

Leg. 

Arm. 

Forearm. 

No.  of 
Cases. 

Deaths. 

No.  of 
Cases. 

Deaths. 

No.  of 

Cases. 

Deaths. 

No.  of 

Cases. 

Deaths. 

No.  of 

Cases. 

Deaths. 

No.  of 

Cases. 

Deaths. 

No.  of 

Cases. 

Deaths. 

No.  of 

Cases. 

Deaths. 

94 

2 

1 

4 

0 

2 

0 

1 

0 

95 

1 

0 

96 

1 

1 

97 

1 

0 

1 

0 

1 

0 

1 

0 

98 

2 

0 

2 

0 

3 

0 

4 

0 

99 

1 

1 

1 

d 

100 

3 

1 

2 

0 

1 

0 

1 

0 

101 

2 

1 

1 

0 

102 

1 

0 

1 

0 

103 

2 

0 

104 

3 

1 

4 

0 

2 

0 

3 

0 

2 

0 

1 

0 

1 

0 

105 

3 

0 

1 

d 

106 

2 

1 

1 

1 

5 

0 

2 

0 

a e 

1 

0 

107 

1 

1 

7 

0 

108 

1 

0 

109 

1 

0 

no 

2 

0 

1 

0 

111 

1 

0 

1 

0 

112 

2 

0 

2 

0 

1 

0 

1 

0 

1 

0 

113 

1 

0 

. , 

1 

1 

114 

4 

1 

1 

0 

115 

1 

1 

2 

0 

2 

0 

2 

0 

116 

1 

0 

1 

0 

117 

2 

1 

118 

1 

0 

, . 

1 

0 

1 

1 

119 

1 

1 

1 

0 

*1 

0 

1 

0 

120 

1 

0 

121 

2 

0 

1 

0 

1 

0 

122 

1 

0 

1 

0 

3 

0 

1 

1 

1 

0 

123 

2 

.1 

2 

1 

2 

0 

124 

2 

0 

2 

1 

1 

0 

. , 

125 

2 

1 

1 

0 

126 

2 

1 

2 

0 

1 

0 

1 

0 

1 

0 

127 

1 

1 

7 

0 

2 

0 

128 

2 

1 

. . 

2 

0 

129 

4 

0 

1 

0 

130 

2 

0 

131 

• ^ 

2 

1 

1 

0 

1 

0 

132 

1 

0 

2 

1 

2 

0 

2 

1 

. . 

1 

0 

133 

4 

1 

2 

0 

3 

0 

3 

0 

2 

d 

134 

3 

2 

2 

0 

1 

0 

1 

0 

135 

1 

0 

3 

0 

1 

0 

3 

0 

136 

1 

1 

137 

1 

*1 

2 

0 

3 

0 

1 

0 

3 

0 

138 

1 

0 

2 

1 

139 

1 

0 

1 

0 

140 

2 

0 

1 

0 

2 

0 

4 

0 

2 

0 

141 

1 

0 

1 

0 

1 

0 

2 

0 

1 

0 

1 

0 

142 

5 

9 

4 

1 

3 

d 

4 

0 

143 

2 

0 

1 

0 

144 

1 

0 

1 

0 

-1 

••  1 

COUNTKY  AMPUTATION  STATISTICS. 


299 


300 


HOSPITALISM. 


No.  of  the 
Schedules. 

Primary. 

Til 

sli. 

Leg. 

Arm. 

Forearm. 

No.  of 
Cases. 

Deaths. 

No.  of 
Cases. 

Deaths. 

No.  of 
Cases. 

Deaths. 

No.  of 

Cases. 

Deaths. 

19G 

1 

0 

1 

0 

197 

1 

0 

1 

0 

198 

1 

0 

1 

0 

199 

1 

1 

200 

3 

1 

1 

0 

1 

0 

201 

1 

0 

202 

1 

0 

203 

1 

0 

204 

205 

1 

0 

7 

0 

1 

0 

206 

, , 

3 

1 

1 

0 

207 

1 

0 

208 

1 

0 

209 

1 

0 

210 

3 

1 

1 

1 

1 

0 

2 

0 

211 

2 

0 

2 

0 

3 

0 

1 

0 

212 

1 

0 

213 

1 

0 

214 

4 

0 

1 

0 

1 

d 

215 

1 

1 

216 

1 

0 

217 

. , 

1 

0 

218 

1 

0 

219 

1 

0 

1 

0 

2 

0 

220 

1 

1 

221 

1 

d 

222 

223 

1 

0 

. . 

224 

1 

0 

225 

226 

2 

0 

1 

0 

1 

0 

227 

20 

6 

7 

2 

6 

0 

5 

0 

228 

1 

0 

1 

0 

229 

1 

0 

/230 

1 

0 

231 

2.32 

2 

1 

3 

0 

233 

1 

0 

234 

1 

0 

235 

1 

0 

1 

0 

236 

*2 

1 

3 

1 

1 

d 

237 

1 

0 

2 

1 

2 

0 

238 

1 

0 

239 

1 

0 

2 

0 

240 

1 

1 

3 

0 

1 

0 

1 

0 

241 

1 

0 

1 

0 

242 

1 

0 

243 

1 

0 

1 

0 

2 

0 

244 

1 

0 

245 

1 

0 

246 

•• 

1 

1 

Secondary. 


Thigh. 


Le.sr. 


Arm.  Forearm. 


_ 

1 


13 

2 


^210 


Deaths. 


COUNTRY  AMPUTATION  STATISTICS. 


301 


302 


HOSPITALISM. 


COUNTRY  AMPUTATION  STATISTICS. 


303 


General  Summary  of  Table  I. 

The  general  summary  of  the  results  shown  in  the  preceding 
Table  may  be  stated  under  the  following  four  heads : — 


1.  Total  Mortality  of  all  the  Amputations. 

When  all  the  amputations  are  placed  together,  and  all  the 
deaths  from  them,  the  result  as  to  the  general  mortality  is  as 
follows : — 

Total  number  of  cases,  2098  j 
Total  number  of  deaths,  226  ; 

Or  1 in  every  9 '2  died;  or  10 '8  in  every  100. 

2.  Mortality  of  the  Individual  Amputations. 

When  we  calculate  the  mortality  attendant  upon  the  four 


304 


HOSPITALISM. 


individual  amputations  of  the  Thigh,  Leg,  Arm,  and  Forearm,  the 
results  stand  thus  : — 

Thigh  cases,  669  ; deaths,  123  ; or  1 in  5*4  ; or  18*3  per  cent. 
Leg  „ 618;  „ 82;  or  1 in  7*5;  or  13*2  „ 

Arm  „ 433;  „ 19;  or  1 in  22*8;  or  4*3  „ 

Forearm  „ 378  ; „ 2 ; or  1 in  189;  or  0*5  „ 

3.  Mortality  from  the  Araputations  that  were  Primary  or  for  Injury. 

The  death-rate  among  the  class  of  amputations  for  injuries  or 
their  results  may  be  represented  thus  : — 

Thigh  cases,  313  ; deaths,  80  ; or  1 in  3*9  ; or  25*5  per  cent. 

Leg  „ 409  ; „ 57  ; or  1 in  7*1  ; or  13*4  „ 

Arm  „ 344;  „ 14;  or  1 in  24*5;  or  4*0  „ 

Forearm  „ 318;  „ 2 ; or  1 in  159;  or  0*6  „ 

4.  Mortality  from  the  Amputations  that  were  Secondary  or  for  Disease. 
The  death-rate  among  this  class  stands  as  follows  : — 

Thigh  cases,  356  ; deaths,  43  ; or  1 in  8*3  ; or  12*0  per  cent. 

Leg  „ 209  ; „ 25;  or  1 in  8*3;  or  12*0  „ 

Arm  „ 89;  „ 5 ; or  1 in  17*8;  or  5*6  „ 

Of  amputations  of  the  forearm  for  disease,  60  cases  v.^ere 

reported  in  the  schedules.  None  of  the  60  patients  died. 


COUNTRY  AND  HOSPITAL  AMPUTATIONS. 


305 


CHAPTER  11. 


STATISTICS  OF 


2098  COUNTRY  AMPUTATIONS. 
2089  HOSPITAL  AMPUTATIONS. 


1.  On  some  Minor  Points  pertaining  to  the  CoLLEcnoN  of 
Amputations  in  Table  I. 


My  chief  object  in  collecting  the  2000  and  odd  cases  of  ampu- 
tation recorded  in  Table  I.  was  to  ascertain  what  was  the  mortality 
in  private  country  and  provincial  practice  of  the  four  major  amputa- 
tions of  the  limbs’  w’hen  taken  as  a class  of  operations, — when  taken 
as  individual  operations, — and  when  performed  for  the  effects  of 
injury  or  for  the  effects  of  disease.  As  already  stated,  however, 
there  was  added  to  the  schedule  which  was  intended  to  elicit  these 
leading  data,  a vacant  space,  headed  “ Remarks,”  under  the  belief 
that  valuable  observations  of  various  kinds  might  be  appended 
by  some  of  the  reporters.  In  this  hope  I have  not  been  disap- 
pointed. Perhaps  I might  have  added  several  more  special  and 
direct  questions  on  various  minor  matters  ; but  I avoided  doing  so 
under  the  conviction  that,  if  I asked  too  much  or  too  many  things, 
I should  be  liable  to  get  the  primary  and  simple  points  regarding 
the  mortality,  buried  and  lost  in  points  of  infinitely  less  importance  ; 
or,  indeed,  receive  no  answer  at  all. 

In  the  present  and  following  chapters  I shall  throw  together 
some  of  the  more  interesting  items  of  information  contained  in  these 
“ Remarks.” 


Double  Amputations  in  twenty-three  of  the  Cases. 

The  cases  enumerated  in  Table  1.  amount  to  2098.  Tliis  is  the 
number  of  patients  operated  upon  ; but  the  actual  number  of  ampu- 
tations performed  was  greater,  being  2122  in  all.  For  in  twenty- 
three  instances  of  severe  injuries,  involving  two  extremities,  the 

^ Let  it  be  here  explicitly  noted,  that  the  present  collection  of  limb  amputa- 
tions in  country  and  in  hospital  practice  is  limited  to  the  four  amputations 
through  the  bones  of  the  thigh,  leg,  arm,  and  forearm,  and  does  not  include  any 
of  the  other  six  amputations  of  the  limbs  through  the  joints — viz.  the  hip,  knee, 
ankle,  shoulder,  elbow,  and  Avrist  joints.  To  have  taken  into  the  investigation 
disarticulations  or  amputations  through  the  joints,  Avould  have  complicated  and 
extended  the  whole  inquiry  very  greatly  and  very  needlessly. 


306 


HOSPITALISM. 


patients  were  subjected  to  more  than  one  amputation ; as  the 
thigh  and  leg,  two  legs,  etc.  Sometimes,  in  the  schedules,  as 
they  were  returned  to  me,  these  double  amputations  were  entered 
as  two  amputations ; but  in  accordance  with  the  practice  followed 
I believe,  in  most  hospital  returns,  I have  given  in  the  table  each 
double  amputation  as  one  case ; entering  it  under  the  head  of  the 
greater  of  the  two  amputations  that  were  performed,  when  the  two 
amputations  were  on  different  parts  of  the  two  limbs.  Several 
correspondents  who  have  added  few  or  no  “ remarks,”  have,  if  I 
may  judge  from  the  number  of  their  primary  or  traumatic  cases, 
possibly  or  probably  met  with  additional  double  amputations,  though 
they  have  not  considered  them  of  sufficient  interest  to  report  upon 
in  their  returns.^ 

Table  II. — Of  the  Results  op  Twenty-three  Double  Amputations 
AFTER  Complex  Injuries. 


No.  of 
Schedule. 

DOUBLE  PRIMARY  AMPUTATIONS. 

No.  of 
Cases. 

Deaths. 

7 

Both  forearms  . 

1 

0 

22 

Both  legs 

1 

0 

24 

Thigh  and  arm  at  shoulder 

-joint 

1 

0 

31 

Botli  arms 

1 

0 

34  -1 

Thigh  and  arm 

1 

0 

34  -j 

Thigh  and  leg  . 

1 

1 . 

43 

Both  forearms  . 

1 

0 

44 

Both  legs 

1 

0 

ACk  ) 

Both  legs 

1 

0 

Leg  and  arm 

1 

0 

59 

Both  legs 

1 

0 ' 

65 

Both  forearms  . 

1 

0 

78 

Thigh  and  leg 

1 

0 

107 

Arm  and  forearm 

1 

1 

125 

Both  thighs 

• 

1 

1 

133 

Both  thighs 

• 

1 

1 

134 

Thigh  and  arm  . 

• 

1 

1 

135 

Both  arms 

• 

1 

0 

184 

Thigh  and  leg  . 

• 

1 

1 

200 

Both  forearms  . 

• 

1 

0 

Thigh  and  forearm 

1 

0 

344  J 

Arm  and  forearm 

1 

0 

1 

Both  thighs 

1 

1 

Total 

23  ' 

7 

The  mortality  among  these  cases  of  primary  double  amputations 
— viz.  7 deaths  in  46  amputations,  performed  upon  23  individuals^ 
is  strikingly  small,  when  we  take  into  consideration  the  terrible 


^ The  three  cases  of  double  amputation  in  the  Table  occurred  to  Mr.  Hinton 
of  Hinton.  Mr.  Moodie  of  Stirling  and  Dr.  Thomson  of  Motherwell  have  each 
reported  two  double  amputations. 


1 


COUNTRY  AND  HOSPITAL  AMPUTATIONS.  307 

character  of  the  compound  injuries  under  which  the  patients  suf- 
fered. In  our  large  and  metropolitan  hospitals,  as  we  shall  see  in 
the  sequel,  the  mortality  attendant  upon  single  amputations,  primary 
and  secondary,  is  greater.  And,  in  these  hospitals,  double  ampu- 
tations seem  to  be  attended  by  a frightful  mortality.  Out  of  a list 
of  the  last  1 1 double  primary  amputations  performed  in  the  Edin- 
burgh Infirmary,  and  furnished  to  me  by  Mr.  M‘Dougall,  10  of  the 
patients  died.  The  case  which  survived  was  a double  amputation 
through  the  knee-joints,  and  does  not  therefore  properly  belong  to 
the  present  inquiry,  as  it  excludes  all  operations  through  the  joints. 

Some  of  the  double  amputations  are  shown  in  the  table  to  be 
greatly  more  dangerous  than  others ; those  involving  the  thigh 
being  apparently  much  the  most  perilous. 

Upper  Extremities. — Out  of  4 double  amputations  in  which  both 
forearms  were  removed,  all  the  4 patients  recovered ; 2 other 
patients,  in  whom  both  arms  were  amputated,  recovered  also ; as 
did  1 in  whom  the  opposite  arm  and  forearm  were  removed ; and 
I only  out  of  the  8 in  whom  the  double  amputations  were  confined 
to  the  upper  extremities  died.  In  this  eighth  and  fatal  case,  the 
right  arm  and  left  forearm  were  amputated. 

Lower  Extremities. — In  4 cases  both  legs  were  amputated ; all 
the  patients  survived.  In  a fifth  the  amputation  of  the  leg  and 
aim  proved  successful.  In  10  cases  in  which  amputation  of  the 
thigh  formed  one  of  the  forms  of  dismemberment,  G deaths  occurred. 
In  I the  thigh  and  forearm,  and  in  2 the  thigh  and  arm,  were  am- 
putated ; all  three  recovered.  In  3 cases  a thigh  and  the  opposite 
leg  were  amputated ; 2 out  of  the  3 succumbed.  In  3 cases  both 
thighs  were  amputated ; all  three  patients  died.^ 

^ In  an  annotation  to  his  schedule,  Mr.  Anderson  of  Castle-Douglas  relates  a 
case  where  a double  amputation  was  performed  by  machinery,  and  not  by  the 
knife  of  the  surgeon  ; and  which  is,  therefore,  not  included  in  Table  1.  But  this 
double  amputation  deserves  to  be  recorded.  “A  girl,”  he  states,  “about  ten 
years  of  age,  amusing  herself  putting  straws  into  a lint-mill,  had  her  hands 
caught  by  the  machine,  and  gradually  drawn  inwards,  till  stopped  at  the 
shoulders,  when  they  were  completely  detached  close  to  the  shoulder-joints. 
There  was  no  bleeding,  although  the  arteries  were  seen  on  the  surface  of  the 
wounds  pulsating  strongly.  One  sharp  projecting  piece  of  bone  was  removed  by 
pliers.  Nothing  more  was  done,  as  the  attempt  to  remove  ragged  pieces  of 
muscle  and  skin  produced  such  violent  excitement  in  the  girl — it  was  before 
chloroform  was  known — that  we  wer.^  compelled  to  desist.  Wet  rags  were  lain 
over  the  wounds  ; everything  went  on  well  ; granulations  sprang  up  and  covered 
the  ends  of  the  bones  ; and  in  due  time  cicatrisation  was  completed  with  so  little 
assistance  that,  it  may  be  said,  the  mill  amputated  the  arms,  and  the  vis  mccli- 
catrix  naturm  effected  the  cure  of  the  stumps.  ” 


308 


HOSPITALISM. 


Age  of  the  Patients. 

I originally  sent  out  no  query  about  the  ages  of  the  patients 
operated  upon,  because  it  seemed  to  be  unnecessary.  For  there 
appeared  no  reason  whatever  for  believing  that  the  general  average 
of  ages  of  those  submitted  to  amputation  in  country  practice  would 
differ  in  any  important  respect  from  the  general  average  of  ages  of 
those  submitted  to  amputation  in  hospital  practice.  Some  of  my 
correspondents  have  incidentally  given  the  ages  of  their  patients. 
These  ages  vary  from  1 up  to  84  ‘ years.  The  youngest  subject 
noted  is  an  infant  about  twelve  months  old.  The  case  occurred  in 
the  practice  of  Dr.  Livingston  of  Wishaw.  The  child’s  arm  was 
smashed  by  a railway-waggon,  and  Dr.  Livingston  was  obliged  to 
amputate  the  limb  high  up.  The  little  patient  did  well  for  ten 
days,  but  ultimately  sank.  Several  gentlemen  speak  of  the  ampu- 
tations which  they  practised  being  in  “ old  ” or  “ very  old  ” indi- 
viduals, without  specifying  more  particularly  this  state  of  advanced 
age.  In  others  of  these  instances  the  age  of  the  patients  is  specified, 
and  the  following  table  shows  the  cases  of  this  kind  which  I have 
found  in  the  annotations  of  my  correspondents  : — 


Table  III. — Result  of  Amputations  by  Country  Practitioners  on 
Patients  of  70  Years  and  upwards.  . 


No.  of 
Schedule. 

Age  of  Patient. 

Special  Amputation. 

Recovered. 

Died. 

For  Injury. 

For  Disease. 

289 

70 

Leg  . 

0 

1 

188 

70 

Arm  . 

1 

0 

45 

70 

Leg  . 

0 

1 

118 

Above  70 

. 

Thiglx 

0 

1 

273 

72 

Arm  . 

1 

0 

2G8 

Above  72 

. 

Thigh 

1 

0 

43 

73 

. 

Leg  . 

1 

0 

131 

73 

Arm  . 

1 

0 

354 

74 

Leg  . 

. 

0 

1 

240 

74 

Leg  . 

' 1 

0 

257 

74 

Arm  . 

0 

1 

222 

75 

Forearm 

1 

0 

359 

75 

Arm  . 

1 

0 

43 

77 

Leg  . 

0 

1 

295 

78 

Leg ; ; 

1 

0 

144 

Between  70  and  80 

Foj’earm 

1 

0 

106 

80 

Leg  . 

1 

0 

27 

Above  80 

Tliigh 

0 

1 

117 

„ 80 

• • 

Leg  . 

1 

0 

141 

82 

• 

Thigh 

1 

0 

1 

84 

Thigh 

1 

0 

17 

84 

. 

Thigh 

0 

1 

Total 

14  I 

8 1 

COUNTRY  AND  HOSPITAL  AMPUTATIONS. 


300 


This  mortality  rate  of  1 death  in  2*7,  or  of  8 out  of  22,  is,  as 
we  shall  see  subsequently,  not  more  than  the  rate  of  mortality  in 
most  of  our  large  and  metropolitan  hospitals  in  patients  of  all  ages ; 
and  consequently  forms  an  amount  of  mortality  much  smaller  than 
could  be  a priori  expected  in  a set  of  patients  operated  upon  after 
they  had  reached  or  passed  the  “ threescore  years  and  ten.” 

Injuries  and  Diseases  necessitating  the  Amputation. 

Though  the  causes  leading  to  the  amputations  are  often  men- 
tioned in  the  returns,  I do  not  know  that  anything  special  can  be 
adduced  under  this  head. 

In  the  traumatic  or  primary  cases,  the  injuries  noted  are  chiefly 
for  railway  and  other  accidents  connected  with  mining,  iron-works, 
and  various  descriptions  of  machinery.  Some  are  the  results  of 
high  falls  ; several,  and  particularly  the  amputations  of  the  forearm, 
from  gunshot  wounds,  bursting  of  guns,  etc.  The  unguarded 
country  thrashing-machine  is  very  often  mentioned  as  the  source 
of  the  mutilations  that  led  to  amputations  in  the  upper  extremity. 
The  supervention  of  gangrene  following  upon  injuries,  such  as  in 
compound  fractures,  etc.,  is  repeatedly  mentioned  as  the  reason  for 
having  had,  sooner  or  later  after  the  accidents,  recourse  to  amputa- 
tion. In  two  or  three  cases,  suppuration  of  the  knee-joint,  following 
upon  its  puncture  or  injury,  is  noted  as  the  cause  leading  to  the 
operation. 

Among  the  pathological  series,  or  amputations  for  disease,  I find 
annotated  most  frequently  diseases  of  the  joints  and  bones.  In 
various  instances,  the  existence  of  cancerous  deposits  and  ulcers  in 
the  amputated  portion  of  limb,  of  fungus  hsematodes,  of  tumours 
(one  lived  for  twenty  years  after  amputation),^  of  burns  and  their 
effects,  of  frostbites,  of  dry  or  senile  gangrene,  led  to  the  operation. 
In  one  case  it  was  deemed  necessary  to  stay  the  bleeding  from  a 
popliteal  aneurism ; in  another  instance  it  was  had  recourse  to  in 
the  faint  hope  of  arresting  tetanus.  The  patient,  in  the  practice  of 
Mr.  Boyle  of  Newquay,  had  a compound  fracture  of  the  leg,  and 
progressed  favourably  for  twelve  days,  when  symptoms  of  tetanus 
supervened.  Amputation  was  then  adopted  as  a last  resource. 
Death  took  place  sixteen  hours  afterwards. 

^ It  was  a case  of  amputation  of  the  thigh,  in  tlie  practice  of  Dr.  Falla  of 
Jedburgh.  The  tumour  was  fourteen  pounds  in  weight,  extended  from  the  knee 
to  the  ankle,  was  of  a fatty-like  structure  internally,  and  “had  a bleeding  fungus  of 
nearly  five  inches  in  diameter  " on  a portion  of  its  surface.  The  man  (writes  Dr. 
Falla)  is  in  perfect  health  now — twenty  years  after  the  operation. 


310 


HOSPITALISM. 


2.  Causes  of  Death  in  the  Fatal  Cases  of  Amputation. 

The  primary  questions  of  the  actual  death-rate — whether  high 
or  low — attendant  upon  all  the  four  major  amputations  of  the  limbs, 
collectively  and  individually — and  attendant  upon  these  same  am- 
putations when  performed  for  the  results  of  injury  and  for  the  results 
of  disease,  form  the  special  objects  of  our  present  investigation  ; and 
the  whole  inquiry  has  been  conducted  more  particularly  with  a 
view  of  ascertaining  the  relative  effects  of  place  or  locality,  or  of  the 
conditions  of  hospitalism  and  the  conditions  of  private  rural  practice 
upon  the  results. 

My  object  has  been  to  ascertain  as  far  as  possible  the  differences, 
if  any,  in  the  death-rate  of  the  major  amputations  under  the  different 
circumstances  last  alluded  to.  It  does  not  come  within  the  scope  of 
the  present  inquiry  to  push  the  investigation  into  other  more  minute 
matters,  such  as  the  modes  of  performing  the  amputations  by  the 
flap  or  circular  or  ovoid  method,  the  modes  of  arresting  the  hemor- 
rhage, or  the  modes  of  dressing  the  stump,  etc.,  or  the  effects  of  age, 
sex,  season,  etc.,  upon  the  results.  Nor  does  the  pathological  cause 
or  causes  of  death,  in  the  cases  which  ended  fatally,  form  in  any 
direct  way  a special  object  in  our  inquiry.  But  as  few  or  no  data 
on  this  last  point  exist  in  reference  to  amputations  in  rural  practice, 
perhaps  the  following  particulars  may  interest  some  readers : — 

Out  of  the  227  deaths  tabulated  in  Chapter  I.  2,  the  apparent 
causes  of  the  fatal  issue  have  been  returned  in  above  160  of  the 
cases  as  follows  : — 

I.  Shock. — This  is  entered  as  the  most  frequent  cause  of  death ; 
the  patient  sometimes  dying  of  it  upon  the  operating  table ; or 
within  a few  hours ; or  within  a day  or  two.  In  some  cases  the 
shock  from  the  injury  and  the  attendant  hemorrhage  itself  is  men- 
tioned as  being  so  severe  as  to  offer  but  a very  forlorn  hope  for 
the  success  of  the  amputation.  “ Shock  ” is  returned  as  the  cause 
of  death  in  63  cases,  including  36  amputations  of  the  thigh,  21  of 
the  leg,  and  6 of  the  arm.  Of  these  63  cases,  56  were  amputations 
for  the  results  of  injury,  and  7 for  the  results  of  disease. 

II.  Exhaustion  is  returned  as  the  cause  of  death  in  28  cases — 
viz.,  in  19  amputations  of  the  thigh,  and  9 of  the  leg.  Of  the  28 
amputations  ending  ultimately,  after  a few  days,  and  sometimes  after 
weeks,  in  alleged  “ exhaustion,”  1 3 were  primary  and  1 5 secondary 
amputations.  In  some,  the  exhaustion  is  spoken  of  as  combined 
with  delirium  tremens. 


COUNTRY  AND  HOSPITAL  AMPUTATIONS. 


311 


III.  Pijcemia  is  described  as  the  pathological  cause  of  death  in 
8 cases — all  traumatic — viz.,  in  5 amputations  of  the  thigh  and  in 

3 of  the  leg  for  injury  or  its  consequences.  Perhaps  some  surgeons 
would  have  considered  a few  of  the  cases  entered  under  other  heads 
as  referable  to  forms  of  pyjemia. 

IV.  Gangrene  of  the  Stump  is  returned  as  the  cause  of  death  in 
18  cases  ; 12  of  them  primary  and  6 of  them  secondary  amputations. 
In  several  it  existed  before  amputation.  Of  the  18  cases,  8 were 
amputations  of  the  thigh,  and  9 Avere  amputations  of  the  leg.  In 
the  only  2 amputations  of  the  forearm  that  were  fatal,  gangrene 
is  given  as  the  cause  of  death. 

y.  Secondary  Hemorrhage  is  referred  to  as  having  produced  the 
fatal  issue  in  9 cases — viz.,  in  4 amputations  of  the  thigh,  and  5 of 
the  leg.  Of  these  9 amputations,  4 were  primary  or  traumatic,  and 
5 were  secondary  or  for  disease.  In  1 of  the  thigh-amputations, 
the  reporter,  Mr.  Edwards  of  Wiveliscombe,  observes,  “ Death  Avas 
caused  by  hemorrhage  before  and  after  operation,  the  case  being 
one  of  fungus  hsematodes.”  This  Avas  the  only  unsuccessful  case  in 
18  limb-amputations  performed  by  Mr.  EdAvards. 

VI.  Tetanus. — From  it  11  deaths  resulted,  all  of  them,  Avith  one 
exception,  after  amputations  for  injury ; 2 of  them  in  the  practice 
of  one  surgeon.  Of  the  11  deaths,  4 Avere  after  amputations  of 
the  thigh,  6 after  amputations  of  the  leg,  and  one  after  amputation 
of  the  arm. 

VII.  Internal  Injuries. — In  a considerable  number  of  the  cases 
entered  in  the  Table  as  fatal  after  primary  amputations,  the  alleged 
cause  of  death  is  some  injury  or  injuries,  generally  internal,  received 
at  the  same  time  Avith  the  injuries  to  the  limb  that  necessitated  its 
amputation.  In  13  of  these  cases,  7 Avere  amputations  of- the  thigh, 

4 of  the  leg,  and  2 of  the  arm.  The  coexistent  internal  lesions  re- 
turned as  the  causes  of  death  Avere  in  different  cases  injuries  of  the 
brain,  lungs,  bladder,  fractures  of  the  skull,  ribs,  etc.^ 

^ Internal  Injuries  in  some  of  the  fatal  Primary  Ainimtations. — Take,  for 
example,  the  following  extracts  as  illustrations  of  the  remarks  in  the  text  : — 
“ The  death  in  the  primary  arm  case  cannot  fairly  be  put  down  as  a death  from 
amputation,  as  the  person  Avas  otherwise  severely  injured,  and  actually  died  of 
brain  concussion  and  compression  a few  hours  after  the  operation.” — Mr.  Troup 
of  Auehtermuehty.  “ The  case  of  fatal  primary  amputation  of  the  leg  Avas  one  of 
railAA'ay  smash,  and  Avas  complicated  Avith  fracture  of  the  skull  and  concussion  of 
the  brain.  The  cause  of  death  Avas  encephalitis.  ” — Dr.  Drew  of  Chapeltown.  “ In 
the  fatal  primary  amputation,  the  patient  really  died  in  consequence  of  compres- 
sion of  the  brain  from  exti’avasated  blood,  having  a fracture  of  the  skull.  ” — Mr, 
Grindrod  of  New  Mills.  In  one  fatal  case  out  of  nine  amputations,  “the  one 


312 


HOSPITALISM. 


VIII.  Miscellaneoua  Causes.— Oi  chest  affections  returned  as 
causes  of  death  are  several  inflammatory  complications,  as  4 cases 
of  fatal  pneumonia,  3 of  bronchitis,  2 of  pleurisy,  and  1 of  hydro- 
thorax. Pulmonary  phthisis  is  entered  as  the  cause  of  death  in  7 
or  8 patients.  Gastric  irritation  of  several  weeks’  duration  after 
the  amputation,  and  chronic  and  acute  diarrhoea,  are  reported  aS 
the  causes  of  death  in  three  or  4 cases ; convulsions  in  2 or  3 
others  ; encephalitis  in  1 ; hectic  fever  and  suppurations  in  2 more  ; 
and  a large  abscess  of  the  neck  in  a third  ; erysipelas  formed  a fatal 
complication  in  I case ; 1 died  of  scarlatina ; 1 in  the  eighteenth 
day  after  operation,  of  an  attack  of  influenza ; 1 some  weeks  after, 
of  general  anasarca,  the  stump  being  “perfectly  healed  before 
death,”  etc. 

Date  of  Death. — In  some  returns  of  amputations  which  have 
been  published  in  this  and  in  other  countries,  it  has  been  some- 
times held  justifiable  to  enter  a case  as  successful  when  the  patient 
survived  the  operation  above  a certain  limited  period,  as  four,  five, 
or  six  weeks.  I have,  however,  entered  the  cases  as  fatal,  even 
when  death  did  not  take  place  for  a longer  period,  and  the  patho- 
logical cause  of  it  was  not  directly  connected  with  the  operation,  as 
in  the  last  case  mentioned  in  the  preceding  paragraph.  Or  take 
phthisis  pulmonalis  as  an  example.  In  relation  to  one  of  his  thigh- 
amputations  for  chronic  disease  of  the  knee,  Dr.  Gavin  of  Strichen 
remarks,  “Death  took  place  about  a month  after  amputation.  It 
was  really,”  he  adds,  “ a case  of  death  from  pulmonary  consumption  : 
for  at  no  time  were  there  any  symptoms  directly  caused  by  the 

death  was  not  the  result  of  the  operation,  but  rather  of  the  extent  and  severity  of 
the  injury  which  rendered  the  operation  necessary.” — Mr.  Baillie  of  Markmcli. 
In  a fatal  thigh-amputation,  the  patient  “died  in  consequence  of  internal  in 
juries.” — Dr.  Paterson  of  Bridge-of- Allan.  In  two  fatal  primary  amputations  of 
the  thigh  and  leg,  “ the  deaths  resulted  directly  from  hsemorrhage  jprior  to  the 
operation,  and  therefore,  it  is  scarcely  fair  to  count  them.” — Mr.  Fames  of  Bid- 
ham.  “Hardly  expected  my  patient  to  recover  from  his  amputation,  in  conse. 
quence  of  the  severe  nature  of  his  injury  and  the  loss  of  blood  ; for  he  had  hi» 
leg  completely  severed  at  the  h nee-joint  by  the  friction  of  a heavy  pit-chain 
and  lost  a great  amount  of  blood  before  I saw  him.  ” — Mr.  Dow  of  Dunfermline. 
“ Out  of  fourteen  cases,  with  two  deaths,  my  leg  case  was  fatal  from  injury  to 
the  bladder,  and  I had  a shoulder-joint  amputation  which  was  fatal  from  injuriefi 
to  the  lungs.  ” — Dr.  Maclatchy  of  KilmarnoeJc.  “ The  death  after  amputation  ol 
the  thigh  occurred  in  the  case  of  a man  who  fell  to  the  ground  from  a great 
height.  He  sustained  a had  compound  fracture  of  the  thigh,  and  was,  besides, 
much  injured  internally,  surviving  the  operation  only  48  hours.’  1 do  not  con- 
sider  his  death  fairly  assignable  to  the  operation.  Several  of  his  ribs  were  broken, 
his  lungs  injured,  and  general  emphysema  supervened.” — Dr.  Steele  of  Montrose  ; 
etc.  etc.  etc. 


COUNTRY  AND  HOSPITAL  AMPUTATIONS. 


313 


operation  that  produced  any  anxiety.”  Out  of  other  instances  in 
which  tubercular  phthisis  is  returned  as  the  cause  of  death  after 
amputation,  there  is  one  of  amputation  of  the  thigh  by  Mr.  Day  of 
Harlow,  where  the  patient  died  after  six  weeks ; another  of  thigh- 
amputation  by  Mr.  Donald  of  Ayr,  where  the  patient  died  two  months 
after  the  operation  ; and  a third  by  Dr.  Henry  of  Arroquhar,  where 
death  did  not  supervene  till  three  months.  But  I have  placed  all 
these  instances  as  amputations  followed  by  death,  though  the  date 
of  death  and  the  cause  of  it  might  possibly,  in  the  opinion  of  some, 
have  taken  them  and  other  like  cases  out  of  the  category  of  fatal 
issues.  Again,  Dr.  Forrest  of  Motherwell,  in  reporting  13  cases  of 
amputation  which  he  had  performed,  remarks,  in  reference  to  one 
fatal  primary  leg-amputation, — “ The  amputation  did  icell,  but  the 
thigh  was  severely  bruised,  deep-seated  abscess  formed,  and  he  died 
from  exhaustion  at  the  end  of  four  months.”  Perhaps  in  respect  to 
this  and  similar  cases  it  might  be  argued  that,  as  “ the  amputation 
did  well,”  and  was  not  apparently  the  pathological  cause  of  the 
patient’s  death,  the  death  should  not  be  entered  as  the  result  of  the 
amputation.  I have  followed,  however,  in  this  and  other  examples, 
the  safer  statistical  rule  of  holding  such  cases  to  be  amputations 
ending  in  death  ; as  is  done,  I believe,  in  those  hospital  returns 
that  are  the  most  to  be  relied  upon  for  their  accuracy. 

3.  Classes  of  Patients  on  whom  the  Two  Thousand  Ampu- 
tations WERE  PERFORMED;  AND  THE  GENERAL  CHARACTER 

OF  THEIR  Habitations. 

In  the  schedules  sent  out,  in  addition  to  the  results  of  the  four 
amputations  of  the  limbs,  I stated  that  it  would  be  considered  an 
additional  favour  if  my  correspondents  would  inform  me  whether 
their  cases  were  in  persons  belonging  to  the  upper,  the  middle,  or 
the  lower  classes,  and  whether  the  character  of  their  habitations 
appeared  to  influence  the  chances  of  death  or  recovery. 

A very  few  of  the  two  thousand  patients — not  above  half-a-dozen 
— are  reported  to  me  as  belonging  to  the  upper  classes  ; and  a much 
larger  number — perhaps  eight  or  ten  per  cent  of  the  whole — as 
belonging  to  the  middle  classes  of  society.  But  the  great  mass  of 
those  operated  upon  were  artisans,  labourers,  farm-servants,  miners, 
iron-workers,  quarrymen,  etc.,  or  some  members  of  their  families,— 
in  short,  individuals  belonging  to  such  a class  as,  in  our  large  towns 
and  cities,  would  be  generally  sent  into  hospitals. 


314 


HOSPITALISM. 


The  house  accommodation  of  this  latter  class,  upon  whom  the 
amputations  were  thus  chiefly  or  almost  entirely  performed,  was  not 
such  as  most  hospital  surgeons  would  deem  eligible.  In  many  cases 
the  chamber  in  which  the  patient  was  laid,  even  when  small,  was 
no  doubt  clean,  comfortable,  and  tidy ; but  in  most  the  bed  and 
other  accommodation  was  sufficiently  stinted  and  limited.  A few 
extracts,  however,  from  the  notes  of  some  of  my  correspondents  will 
illustrate  this  observation  better  than  any  didactic  statement. 

A large  number  of  the  cases  of  amputation  were  performed  at 
their  own  houses  on  Workers  in  mines,  iron-factories,  etc.  Their 
house  accommodation  is,  as  a rule,  usually  rather  poor ; but  the 
general  free  ventilation  of  their  cottages  and  hovels  more  than  com- 
pensates for  their  other  deficiencies.  Thus,  Dr.  Stewart  of  Kirkin- 
tilloch, in  sending  me  a list  of  25  limb-amputations  which  he  had 
performed,  with  24  recoveries  and  one  death,  remarks  : — “ All  my 
operations,  except  one,  were  among  miners.  Their  dwellings  were 
composed  of  two  rooms,  but  the  doors  were  always  kept  open.  The 
only  death  in  my  surgical  practice  (being  one  in  ten  primary  am- 
putations of  the  thigh)  was  in  a fisherwoman,  who  met  with  a rail- 
way accident.  She  died  of  bronchitis  ten  days  after  the  operation. 
In  the  operations  for  the  scrofulous  diseases  of  joints,  I found  that  the 
patients  immediately  began  to  improve  after  the  operation  was 
performed,  and  all  made  good  recoveries.”  In  his  schedule,  Dr. 
Boyd  of  Slamannan  observes  : — “ In  most  of  my  cases  the  domestic 
accommodation  has  been  of  the  most  defective  nature,  but  country 
air  and  thorough  ventilation  from  open  doors  and  constant  fires 
atone  for  many  other  deficiencies.  ...  I would  consider  it,” 
he  adds,  “ my  duty  to  undertake  a formidable  operation  in  a 
colliery  row  rather  than  send  in  the  patient  to  the  best-conducted 
hospital,  notwithstanding  the  immeasurable  superiority  of  diagnostic 
skill  and  operative  dexterity  to  be  had  there.”  Out  of  6 limb- 
amputations,  Dr.  Boyd  has  lost  only  one — viz.,  a primary  thigh-am- 
putation in  a stoker,  for  a severe  railway  accident.  He  died  of 
shock  in  two  hours.  Writing  from  the  same  locality,  and  practis- 
ing, I believe,  among  the  same  class  of  patients,  Mr.  Waddell  reports 
to  me  10  cases  of  primary  amputations  of  the  limbs,  all  of  them 
successful.  One  of  my  correspondents,  Mr.  Cribbes  of  Gorebridge, 
after  speaking  of  all  Avounds  in  his  district — and  the  wounds  are 
many  among  his  colliery  patients — healing,  as  regards  both  time 
and  results,  rapidly  and  satisfactorily,  states  : — “ In  none  of  them 
have.  I known  erysipelas  or  fatal  results  ensue  : ” and  he  adds. 


COUNTRY  AND  HOSPITAL  AMPUTATIONS. 


315 


“ these  remarks  apply  wholly  to  the  mining  population,  who  are, 
after  all,  blest  with  nothing  approaching  to  sanitary  measures 
excepting  the  free  blast  of  heaven,  which  whistles  merrily  through 
their  ill-conditioned  dwellings.” 

Some  of  the  patients  subjected  to  limb-amputation  were  located 
in  habitations  still  more  stinted  and  squalid  than  the  cottage  of  the 
collier  and  iron-worker.  In  many  rural  villages  and  towns  the 
poorer  types  of  mechanics  and  their  families  all  live  in  a house  of  a 
single  room ; and  the  country  ploughman  and  labourer  and  their 
families  are  often  similarly  situated.  In  sending  me  a report  of 
seven  cases  of  amputation  of  the  limbs,  with  one  death.  Dr.  Lindsay 
of  Lesmahagow  remarks  : — “ The  whole  of  the  cases  were  in  persons 
belonging  to  the  lower  classes,  and  were  treated  in  small  houses, 
most  of  them  of  one  apartment.”  “ The  six  amputations  performed 
by  me,”  writes  Dr.  Jeffray  of  Ayton,  “ have  all  been  in  persons 
belonging  to  the  lower  classes,  and  all  for  injury.  All  the  opera- 
tions, with  one  exception,  were  performed  in  dwellings  where  there 
was  only  one  apartment,  into  which  all  inquiring  about  the  patient 
were  freely  admitted,  and  where  there  was  no  great  ventilation. 
One  of  the  operations — amputation  of  the  leg — was  performed 
in  a hut  upon  the  North  British  Eailway,  when  in  course  of 
formation,  and  the  end  of  the  table  upon  which  the  patient  was 
laid  had  to  be  brought  to  the  door  of  the  hut,  in  order  that  I might 
have  sufficient  light.”  In  a case  in  which  Mr.  Bloxham  of  Hales- 
Ovven  was  amputating  the  thigh,  “ in  consequence  of  aneurism  of 
the  popliteal  artery,  which  had  been  opened  by  a quack,”  the  patient 
was  living  “ in  a den  about  six  feet  square,  not  high  enough  to 
stand  upright  in,  and  two  farthing  dips  afforded  the  only  light.” 
The  patient  recovered.  Describing  the  accommodation  in  a case  of 
amputation  of  the  thigh,  Mr.  Cade  of  Spondon  remarks,  “ The 
operation  was  performed  in  a miserable  hovel,  for  it  would  be  hardly 
fit  to  call  such  a place  a house, — in  a miserable  bed ; and  yet  the 
case  did  very  well.”  In  reporting  to  me  three  cases  of  primary 
limb-amputation — two  of  the  thigh,  and  one  of  the  leg — which  all 
succeeded,  Mr.  Girvan  of  Maybole  says,  “ In  each  case  there  was  but 
one  apartment  for  the  whole  members  of  the  family  to  live,  cook, 

^ The  fatal  case  was  in  a case  of  tliigh-ainputation.  “ The  operation,”  Dr. 
Lindsay  writes,  “ was  undertaken  with  scarcely  any  hope  of  success.  It  was  a 
case  of  compound  fracture, — not  a severe  one, — which  resulted  in  gangrene  a few 
days  after  the  accident,  apparently  from  some  defect  of  constitution.  Although 
a line  of  demarcation  had  formed  in  the  leg,  there  was  great  infiltration  of  tlie 
tissues  upwards,  even  into  the  pelvis.” 


316 


HOSPITALISM. 


eat,  and  sleep  in.”  Mr.  Balding  of  Eayston,  in  forwarding  the 
results  of  two  cases — one  of  them  amputation  of  the  leg,  and  the 
other  of  the  thigh — strongly  points  out  what  the  differences  between 
healthy  and  unhealthy  cottages  may  lead  to  : — “ The  tAVO  cases  of 
amputation,”  says  he,  “ were  both  performed  in  cottages.  The  case 
of  amputation  of  the  leg  was  in  a dirty  and  unhealthy  cottage,  sur- 
rounded by  every  description  of  filth.  There  was  no  attempt  at 
union  in  the  wound,  the  flaps  sloughed,  and  the  patient  died  nine 
days  after  the  operation.  The  other  case,  that  of  amputation  of  the 
thigh,  was  performed  in  a clean  and  healthily-situated  cottage.  The 
patient’s  recovery  was  more  rapid  than  was  ever  witnessed  in  any 
hospital.  At  the  expiration  of  a fortnight  he  may  be  described  as 
having  been  almost  Avell.” 

Dr.  Irvine  of  Pitlochrie  has  performed  amputation  of  the  limbs 
in  1 2 cases,  and  makes  an  observation  upon  the  houses  in  his  High- 
land district,  which  seems  to  me  of  importance.  The  only  case  of 
the  12  that  died  was  an  old  drunkard  of  84  years  of  age.  “Ex- 
cepting this  instance,”  Dr.  Irvine  writes,  “ I have  lost  no  cases  after 
any  capital  operations.  The  1 2 amputations  were  all  in  the  lower 
classes.  Some  of  their  houses  were  small  and  dark,  but  as  the  walls 
were  badly  built,  and  the  roofs  thatched,  the  ventilation  was  there- 
fore good.”  Dr.  Irvine  believes  that  the  introduction  into  Highland 
and  other  districts  of  the  close  slated  instead  of  the  open  thatched 
roof,  is  proving  unsanitary  where  the  families  are  not  yet  educated 
up  to  the  necessary  amount  of  tidiness  and  cleanliness. 

In  addition  to  the  occasionally  wretched  house  accommodation 
of  the  patients,  their  beds  were  sometimes  of  the  Avorst  construction 
in  a sanitary  point  of  view,  being  made  on  the  old  plan  of  building 
them  closely  off,  with  an  inclosure  or  box  of  wood  all  around,  and 
alike  on  the  sides  and  top.  Dr.  Johnston  Avrites  me,  that  in  the 
earlier  years  of  his  practice,  and  before  becoming  connected  with  the 
Montrose  Hospital,  he  performed  several  limb-amputations  in  the 
country.  “ All  the  patients,”  he  says,  “ belonged  to  the  labouring 
class,  and  Avere  treated  in  the  obnoxious  box-bed  Avhich  is  in  univer- 
sal use  among  this  class  in  the  rural  parts  of  Forfar  and  Kincardine- 
shire.” ^ 

In  reporting  to  me  12  cases  of  amputation  of  the  limbs  Avhich  he 

^ Of  the  11  patients,  2 died  from  shock  shortly  after  primary  amputations, 
one  heiiig  a woman  of  almost  80  years  of  age,  Avith  comminuted  fracture  of  the 
leg  and  compound  dislocation  of  the  ankle  ; and  the  second  a lunatic,  in  Avhom 
the  arm  Avas  smashed  and  destroyed 


• COUNTRY  AND  HOSPITAL  AMPUTATIONS. 


317 


has  performed,  Dr.  Hamilton  of  Dairy  makes  a remark,  which  is,  I 
think,  highly  worthy  of  citation.  “ It  has  long,”  he  states,  “ been 
my  belief  that  the  success  of  the  treatment  of  amputation  and  of 
compound  fractures  was  greater  in  private  than  in  hospital  practice, 
even  when  the  comforts  and  surroundings  were  totally  unequal  to 
those  of  the  Hospital.  I believe,”  Dr.  Hamilton  adds,  “ that  isola- 
tion has  much  to  do  with  ^7.”  I doubt  not  that  the  segregation  of  the 
sick  from  the  sick — every  diseased  man  being  a focus  of  more  or  less 
danger  to  the  diseased  around  him — is  a principle  of  no  small  moment 
and  value. 

4.  Severity  of  some  of  the  Cases  that  recovered. 

It  has  been  sometimes  maintained  that  all  the  most  severe  and 
formidable  cases,  and  classes  of  cases,  of  injury  and  disease  among 
the  country  poor  are  more  likely  to  be  sent  into  hospitals  than 
treated  at  home  ; and  that  this  circumstance  alone  specially  accounts 
for  the  higher  hospital  danger  and  mortality  in  limb-amputations. 

The  most  dangerous  class  of  amputations  of  the  limbs  consists  of 
primary  amputations  required  for  injury ; and  the  most  perilous  of 
all  amputations  in  the  continuity  of  the  bones  is  amputation  of  the 
thigh  for  injuries  inflicted  by  railways,  mining,  machinery,  etc.  In 
his  very  able  work  on  Surgery,  Professor  Erichsen  observes  : — “ It 
is  more  especially  primary  amputations  of  the  lower  extremities, 
and  particularly  those  of  the  thigh,  that  are  attended  by  very  fatal 
results.  Of  the  46  cases  of  primary  amputation  of  the  thigh 
recorded  by  Malgaigne,  34  perished.  And  of  24  cases  recorded  by 
South,  Lawrie,  and  Peacock,  as  occurring  at  St.  Thomas’s  Hospital, 
the  Glasgow  Infirmary,  and  the  Edinburgh  Infirmary,  every  one 
proved  fatal.  This  similarity  of  result,”  Mr.  Erichsen  adds,  “ occur- 
ring in  different  institutions,  shows  clearly  that  this  operation  is  one 
of  the  most  hital  in  surgery,  and  that  the  great  mortality  attending 
it  is  inherent  to  it,  and  not  dependent  upon  local  or  accidental  cir- 
cumstances.” 

According,  therefore,  to  the  theory  that  the  cases  requiring  the 
most  formidable  and  fatal  operations  are  generally,  if  not  system- 
atically, forwarded  from  the  country  into  the  city  hospital,  primary 
amputations  of  the  thigh  should  be  found  in  far  greater  numbers  in 
the  returns  of  large  city  hospitals  than  in  rural  practice.  Is  it  so  1 

Among  the  2098  cases  of  limb-amputations  collated  in  Table  I. 
from  rural  and  provincial  practice,  there  are  313  cases  of  primary 


318 


HOSPITALISM. 


amputation  of  the  thigh,  with  80  deaths ; or  very  nearly  1 death  in 
every  4 operated  upon. 

Among  2089  cases  of  limb-amputations  collated  in  Table  XL 
(see  the  sequel)  from  eleven  large  and  metropolitan  hospitals,  there 
are  304  cases  of  primary  amputation  of  the  thigh,  with  196  deaths; 
or  1 death  in  every  L5  operated  upon. 

The  proportionate  number,  therefore,  of  primary  amputations  of 
the  thigh,  is  thus  as  nearly  as  possible  the  same  in  country  practice 
as  in  large  hospital  practice — being  14’8  per  cent  of  the  whole  in 
the  first,  and  14'5  per  cent  of  the  whole  in  the  last;  but  the  mor- 
tality attendant  upon  the  operation  is  more  than  twice  and  a half  sls 
high  in  large  hospital  practice  as  it  is  in  country  practice. 

Injuries,  indeed,  so  serious  as  to  require  such  a grave  operation 
as  amputation  of  the  thigh  or  leg  ought,  perhaps,  as  a general  rule, 
not  to  be  forwarded  from  the  country  into  a city  infirmary.  Patients 
so  damaged  and  shattered  would  have  a far  better  chance  of  life  if 
they  were  operated  upon  and  kept  in  a railway  shed,  or  in  a country 
hovel,  than  by  being  carried  to  a distance  into  the  richest  and  best 
conducted  hospital.  Chance  has  sometimes  preached  this  lesson. 
Thus  Dr.  Carmichael  of  Burntisland — a town  lying  on  the  opposite 
side  of  the  Forth,  at  a distance  of  some  seven  miles  from  the  Edin- 
burgh Infirmary — states  to  me  that  since  he  began  to  practise  there, 
three  years  ago,  he  had  sent  6 cases  of  severe  injuries  requiring 
amputation  of  the  limbs  to  the  Edinburgh  Hospitals.  All  the  6 
died.  In  the  last  case,  however,  which  happened,  the  patient  was 
a middle-aged  man  of  not  a very  robust  constitution,  who  received 
such  very  severe  injuries  of  both  legs  that  it  was  deemed  utterly 
hopeless  to  attempt  to  carry  him  as  far  as  Edinburgh.  Dr.  Car- 
michael, consequently,  retained  the  man  in  comparatively  poor 
accommodation  at  Burntisland,  and  performed  upon  him  the  neces- 
sary double  amputation  of  one  thigh  and  the  opposite  leg.  He  made 
an  excellent  recovery. 

We  have  already  in  Table  II.  entered  16  cases  of  compound 
amputations  of  the  limbs  that  recovered  in  despite  of  the  tremen- 
dous severity  of  the  accidents  and  injuries  that  led  to  the  dire 
necessity,  in  each  of  them,  of  a double  amputation. 

In  some  of  the  remarks  forwarded  to  me  along  with  the 
schedules,  the  severe  and  desperate  character  of  the  injuries  re- 
quiring the  primary  amputations  is  incidentally  alluded  to.  Thus, 
Dr.  Lawrence  of  Cumnock,  who  has  performed  20  amputations  of 
the  limbs  without  a death — 5 for  disease,  and  15  for  injury — 


COUNTRY  AND  HOSPITAL  AMPUTATIONS. 


319 


remarks,  “About  one-third  of  these  cases  were  so  bad  that  I 
thought  it  was  impossible  they  could  recover.”  Six  of  his  cases 
were  amputations  of  the  thigh. 

Dr.  Cullen  of  Airdrie,  who  has  performed,  without  a death,  10 
primary  amputations  of  the  thigh,  and  17  primary  amputations  of 
the  leg,  among  an  iron-working  and  colliery  population,  says  that 
the  deplorable  severity  of  some  of  the  mining  injuries  was  probably 
much  greater  in  the  past  than  it  will  be  in  the  future,  in  conse- 
quence of  the  protection  now  afforded'  to  the  men  by  the  Mines’ 
Inspection  Act.  But  accidents  and  mutilations  of  an  appalling  type 
still  occur  in  some  localities.  Mr,  Davis  of  Aberdare,  who  has  with 
his  own  hand  performed  22  primary  amputations  of  the  thigh,  and 
23  primary  amputations  of  the  leg,  adds  that  7 of  the  thigh-ampu- 
tations were  for  one  terrific  form  of  accident — viz.  compound  dislo- 
cation of  the  knee — an  accident  which  seems  to  be  the  result,  in 
his  district,  of  the  mode  in  which  the  Avorkmen  are  in  the  habit,  by 
applying  their  backs,  of  staying  the  loaded  and  descending  trucks 
in  the  mines. 

Various  instances  have  been  recounted  to  me  of  the  desperate 
and  complicated  nature  of  some  of  the  injuries  from  Avhich  the  am- 
putated patients  recovered.  As  examples,  let  me  cite  from  Dr. 
Kirk  of  Bathgate,  the  two  folloAving  illustrative  cases  of  injury  and 
recovery  in  miners.  Whilst  working  in  the  pit,  above  half-a-ton 
of  solid  rock  fell  upon  one  of  these  men.  This  enormous  mass 
required  to  be  broken  up  before  the  man  could  be  removed  from 
beneath  it.  He  had  the  following  series  of  injuries: — 1.  Fracture 
of  the  left  thigh-bone ; 2.  Compound  comminuted  fracture  of  the 
right  leg,  for  which  amputation  was  performed  below  the  knee-joint; 
3.  Dislocation  of  the  right  hip-joint ; 4.  Lacerated  Avound  of  the 
perineum,  extending  into  the  right  iliac  fossa ; and  5.  Compound 
comminuted  fracture  of  the  metacarpal  bones  of  the  left  hand. 
He  had  afterAA^ards  pyaemia,  Avith  tympanitis ; and  a large  abscess 
formed  over  the  dislocated  thigh.  Under  the  kind  and  able  care  of 
Dr.  Kirk,  this  patient  recovered  ; was  enabled  to  get  about  in  three 
months ; and  noAV  AAmrks  in  the  pit  every  day.  To  quarry  off  the 
block  of  rock  Avhich  fell  upon  him,  required  tAvo  or  three  hours’ 
Avork  on  the  part  of  his  comrades;  and  heAvas  subsequently  removed 
from  the  pit-mouth  in  a cart  to  a room  tAvo  miles  distant.  Dr. 
Kirk  further  informs  me  that  he  treated  shortly  afterAvards  in  the 
same  room  another  miner  from  the  same  pit,  upon  whom  a mass  of 
rock  had  also  fallen.  It  entirely  comminuted  and  ground  the  bones 


320 


HOSPITALISM. 


of  one  knee-joint,  so  as  to  necessitate  the  amputation  of  the  thigh ; 
and  his  head  and  face  were  very  severely  injured.  This  miner  was 
a debilitated  man,  advanced  beyond  fifty,  addicted  to  hard  drinking, 
and  the  subject  of  a chronic  bronchitis.  Yet,  notwithstanding  his 
age  and  his  weakness,  his  drunken  habits,  and  his  troublesome 
cough,  he  recovered  rapidly,  and  without  a drawback.  Would 
these  two  poor  fellows  have  had  much  or  any  chance  of  escape,  if, 
instead  of  being  treated  at  home,  they  had  been  carried  away  into  a 
distant  city  hospital  ? 

The  preceding  remarks  on  the  severity  of  some  of  the  cases  that 
recovered,  refer  chiefly  or  entirely  to  primary  amputations,  or  to 
those  required  for  injuries  or  their  results.  They  tend  to  show  that 
these  primary  amputations ‘in  country  practice  were  necessitated  by 
as  formidable  injuries  as  could  well  be  met  with  in  hospital  practice. 
But  in  the  country,  secondary  amputations,  or  those  for  disease,  are 
also  in  many  instances  necessitated  by  as  unpromising  morbid  local 
lesions  and  morbid  constitutional  states  as  are  met  with  in  large 
hospitals.  A few  of  the  secondary  amputations  entered  in  Table  I. 
had  been,  indeed,  previously  despaired  of  when  the  patients  were  the 
inmates  of  hospitals,  and  yet  afterwards  proved  successful  operations 
in  the  country.  Thus,  for  example,  in  some  notes  on  his  amputa- 
tions, Mr.  Breach  of  Aston-up-Thorpe  observes : — “ All  the  cases 
proved  successful.  One  (a  thigh-amputation)  was  turned  out  of  the 

Infirmary  as  incurable,  the  surgeon  fearing  to  operate,  as  the 

patient  appeared  to  be  in  the  last  stage  of  hectic,  from  ulceration  of 
the  cartilages  of  the  knee-joints  and  caries  of  the  femur.  The 
patient  begged  of  me  to  operate  to  relieve  her  of  her  extreme  pain. 
I reluctantly  yielded  to  her  request.  About  the  third  or  fourth 
day  erysipelas  of  the  stump  took  place.  Betimes  a ring  of  bone  ex- 
foliated, and  she  made  henceforward  a rapid  recovery.  She  is  now 
in  robust  health, — it  being  just  nine  years  since  the  operation.”  In 
speaking  of  another  thigh-amputation, . Mr.  Brookes  of  Shaldon 
observes  : — “ The  patient  was  a sailor  in  the  Boyal  Kavy,  and  v/as 

brought  home  at  his  own  request  from Hospital.  The  case 

was  one  of  diseased  knee,  and  the  operation  was  performed  with 
little  hope  of  success.  It  was,  however,  the  only  chance,  and  all 
went  on  well.”  Dr.  Corbett  of  Orsett  writes  me  in  relation  to  two 
thigh-amputations  which  he  has  successfully  performed,  that  one  of 
his  cases  was  in  a labouring  man,  aged  7 2,  who  “ had  been  in  the 

Hospital  for  some  months,  and  was  discharged  to  die,  as  there 

was  a diiference  of  opinion  as  to  the  possibility  of  recovery  if  an 


COUNTRY  AND  HOSPITAL  AMPUTATIONS. 


321 


operation  was  performed.”  In  reference  to  a case  of  amputation  of 
the  leg,  Mr.  Hallet  of  Axminster  remarks  that  “ the  operation  on 
an  old  sailor  was  performed  on  account  of  caries  of  the  os  calcis, 
and  exostosis  of  the  lower  end  of  the  tibia  and  fibula,  of  many 
years’  standing.  He  had  been  sent  to  an  hospital ; but  the  surgeons 
declined  operating,  fearing  that,  as  his  health  was  such,  he  would 
sink  under  its  effects.  He,  however,  recovered  without  a single 
bad  symptom,  and  lived  in  comfort  for  many  years  afterwards.”^ 

Occasionally  country  patients,  by  the  time  tliat  they  require  to 
be  the  subjects  of  secondary  or  pathological  amputations,  are  already 
so  utterly  sunk  and  debilitated  as  to  be  entirely  incapable  of  being 
moved  off  to  an  hospital ; and  yet  sometimes  make  good  recoveries 
when  the  operation  is  had  recourse  to  at  home.  Dr.  Pairman  of 
Biggar  has  sent  me  reports  of  two  cases,  in  regard  to  which  he 
observes — “ Both  were  in  the  humble  ranks  of  life,  and  operated  on 
by  me  because  reduced  to  a condition  of  such  extreme  weakness  that 
they  could  not  be  removed  to  an  hospital.  Both,  however,  recovered 
admirably.  One  of  them  was  almost  hopeless  from  prostration  before 
the  operation,  and,  as  I think,  would  almost  certainly  have  died  in 
any  hospital.” 

The  patient,  before  at  last  agreeing  to  amputation,  may  have 
lapsed  down  into  the  very  lowest  stage  of  weakness  and  almost 
of  hopelessness — a result  which,  if  I may  judge  from  the  re- 
marks sent  to  me,  not  unfrequently  occurs  in  country  practice. 
Thus,  Mr.  Lawrence  of  Mintlaw  states,  in  reference  to  an  amputation 
of  the  thigh  for  disease  which  was  performed  by  him,  that  the  patient 
“had  long  laboured  under  disease  of  the  knee-joint,  and  was  so 
weak  and  attenuated  that  he  could  not  be  moved  even  to  a table 
for  the  operation ; but  his  recovery  was  rapid,  and  he  got  very 
stout.” 

Several  correspondents  speak  of  the  recovery  of  some  of  their 
patients  in  the  country^  from  secondary  amputations,  as  conditions 

^ In  some  of  the  amputations  for  disease,  there  -was  a remarkable  succession  of 
operations.  Thus,  Mr.  George  of  Keith,  in  commenting  upon  one  of  his  cases  of 
amputation  of  the  leg  for  disease  of  the  ankle-joint,  remarks  that  the  patient, 
a farm-servant,  aged  57,  suffered  a year  afterwards  so  severely  from  affection  of 
the  knee-joint,  that  “ it  was  necessary  to  remove  the  thigh  about  the  middle. 
Eighteen  months  after  the  removal  of  the  thigh  his  right  hand  and  wrist  became 
diseased,  for  which  he  had  the  forearm  amputated.  Previously  to  the  removal 
of  any  of  his  limbs  the  operation  of  lithotomy  was  performed  upon  him  in  Elgin 
Hospital  ; and  he  died,  three  years  after  the  last  amputation,  of  disease  of  the 
bladder.” 

2 Mr.  Harper  of  Holbeach  has  sent  me  the  results  of  above  80  operations 


322 


HOSPITALISM. 


that  scarcely  could  have  been  realised  if  these  same  patients  had 
been  the  inmates  of  city  hospitals.  Mr.  Haig  of  Airth,  for  example, 
in  reporting  to  me  several  successful  cases  of  amputation,  remarks, 
in  regard  to  three  of  his  six  secondary  operations,  “ I feel  certain 
that,  owing  to  the  great  debility  induced  by  the  discharges  from  the 
knee  and  elbow  joints,  a satisfactory  result  could  not  have  been 
looked  for  if  the  patients  had  been  confined  in  the  wards  even  of  the 
best  of  hospitals.”  In  reference  to  four  cases  of  secondary  amputa- 
tion in  his  practice,  in  all  of  which  the  state  of  debility  of  his  patients 
was  complicated  and  extreme,  and  the  cottage  accommodation  most 
defective,  Mr.  Blackburn  of  Barnsley  asserts,  “ All  recovered ; yet 
my  own  belief  is,  that  every  case  would  have  died  if  removed  to  an 
hospital.” 

Many  correspondents  have  casually,  and  yet  so  strongly  ex- 
pressed in  a similar  spirit  the  results  of  their  experience  as  to  ampu- 
tations and  other  operations  succeeding  much  better  in  country  than 
in  hospital  practice,  that  perhaps  the  collation  of  a few  such  opinions 
may  be  interesting. 

5.  Opinions  as  to  Amputations,  etc.,  succeeding  better  in 
Private  Country  than  in  Public  Hospital  Practice. 

There  are  various  reasons  why  cases  of  disease  or  injury  among 
the  poor  in  the  country  requiring  amputation  are  sent  off  to  city 
hospitals.  Enumerating  these  reasons,  in  a late  letter  to  me,  Dr. 
Whitelaw  of  Kirkintilloch  remarks — “In  my  opinion,  country 
patients  are  sent  to  the  city  hospital, /rs/,  by  their  relatives,  because 
they  cannot  give  them  food  at  home  ; because  they  cannot  pay  for 
continued  surgical  attendance ; because  they  have  great  faith  in  the 
head  doctor,  from  whom  there  is  no  appeal ; and  because  they  know 
nothing  of  the  perils  of  hospital  pysemia,  erysipelas,  etc. ; secondly, 
they  are  sent  by  the  country  practitioners,  because  the  accommoda- 
tion, nursing,  and  resources  at  home  are  frequently  quite  inadequate  ; 
because  once  away  to  the  hospital,  the  patient,  probably  a poor 
man,  is  off  the  doctor’s  mind,  and  his  maintenance  does  not  longer 
concern  either  his  employers  or  the  parochial  board  ; and  because, 

wliicli  lie  has  performed  in  country  practice,  with  a view  of  showing  their  relative 
safety  in  the  country.  Among  these  12  were  limb-amputations,  1 died  ; 4 were 
lithotomies,  1 died  ; and  7 were  oases  of  strangulated  hernia,  2 died.  Only  these 
four  deaths  occurred  ; and  the  recoveries  included  cases  of  lithotrity,  of  excision  of 
tumours,  of  removal  of  portions  of  lower  jaw,  of  amputation  of  mamma,  extravasa- 
tion of  urine,  amputations  of  the  hand,  fingers,  etc.  etc. 


COUNTRY  AND  HOSPITAL  AMPUTATIONS. 


323 


if  the  case  turn  out  badly  in  the  hospital,  the  tongues  of  the  village 
gossips  cannot  reflect  on  the  doctor,  ‘ for  the  patient  had  the  best  of 
skill.’  Yet  it  is  my  conviction,”  adds  Dr.  Whitelaw,  “ that  ordinary 
amputations  and  compound  fractures  would  result  in  more  numerous 
and  more  satisfactory  recoveries,  if  treated  in  the  country  with  fair 
skill,  than  if  sent  to  a city  hospital.”  “ As  surgeon,”  observes  Mr. 
Garman  of  Wednesbury,  “ to  large  iron- works  and  collieries,  I may 
be  perhaps  allowed  to  add,  that  compound  fractures  and  other  for- 
midable surgical  lesions  appear  to  do  better  in  the  squalid  homes 
of  the  patients,  although  of  course  suffering  great  deprivation  and 
inconvenience,  than  under  hospital  care.  My  partner  and  myself 
have  long  made  it  a rule  not  to  send  any  formidable  accidents  to 
the  hospital  if  possible.  The  cases  we  send  are  for  the  most 
part  simple  fractures,  and  chronic  sequences  of  accidents.”  Mr. 
Carter  of  Pewsey  states  : “ All  my  cases  of  amputation  occurred 
in  my  pauper  practice,  the  patients  being  of  the  lowest  class  of 
an  agricultural  population.  But  my  undoubted  experience  has  ever 
been,  that  the  poor  recover  much  more  readily  at  their  own  houses 
than  from  the  best  of  treatment  elsewhere.”  “ I can  give,”  avers 
Mr.  Wilson  of  Alton,  “ my  testimony  in  favour  of  operations  being 
performed  among  the  poor  at  their  own  houses  ; and  there  are  few 
cottages  indeed  in  the  south  of  England  in  which  a free  current  of 
air  may  not  be  obtained.”  Dr.  Monckton  of  Eugeley  has  sent  me  a 
note  of  the  results  of  6 amputations  and  80  various  surgical  opera- 
tions which  he  has  performed.  “ Among  all  these,”  he  writes,  “ the 
primary  amputation  through  the  thigh  is  the  only  case  which  had  a 
fatal  result,  whereas  I remember  being  shocked  as  a student  to  see 
operations  performed  in  a London  hospital  for  comparatively  small 
ailments  or  deformities,  which  were  often  followed  speedily  by  a 
fatal  result  from  pyaemia,  erysipelas,  etc. ; and  to  this  day  I hear 
students  remark  upon  the  same  unfavourable  issue  to  small  opera- 
tions most  ably  performed  by  the  first  surgeons  of  the  land.” 
“ Having,”  observes  Mr.  Cann  of  Dawlish,  “ been  house-surgeon  at 
Guy’s  Hospital,  London,  I can,  without  hesitation,  pronounce  in 
favour  of  operations  being  done  in  private  houses.”  “ I have  had,” 
says  Dr.  Guppy  of  Falmouth,  “ many  compound  fractures  among  our 
sailors  and  dock-labourers,  and  my  opinion  is  that  the  mortality  from 
the  graver  operations  and  injuries  is  much  less  in  private  and  country 
practice  than  in  hospitals.”  Mr.  Hardy  of  Byer’s  Green,  Yfillington, 
in  sending  a report  of  a series  of  limb-amputations,  writes : “ I 
have  been  long  of  opinion  that  severe  accidents  in  the  country  are 


324 


HOSPITALISM. 


more  likely  to  do  well  than  when  they  are  sent  to  an  hospital,  and 
I have  never  hesitated  to  express  this  opinion ; for,  living  in  a 
colliery  district,  where  severe  injuries  often  occur,  I have  found 
them  to  do  better  in  their  own  houses  than  when  sent  away  to  an 
hospital,  and  consequently  I have  been  very  chary  in  even  advising 
the  removal  of  such  parties.  Most  of  the  cases  of  amputation  which 
I have  recorded  have  been  caused  by  railway  accidents.  All  the 
patients  suffered  from  shock,  and  the  deaths  recorded  have  been 
from  that  cause  ; none  from  symptoms  of  blood-poisoning.”  In  the 
same  spirit  Dr.  Thomson  of  Motherwell  observes,  “ My  experience 
is  against  sending  any  case  to  hospital  that  can  be  treated  at 
home.  I have  only  sent  for  years  past  lodgers,  or  those  having 
no  house  accommodation.”  “ I have  always,”  writes  Dr.  Loudon 
of  Hamilton,  “studied  to  keep  the  patients  in  their  own  homes 
when  their  means  would  admit  of  it,  and  have  only  sent  those  cases 
to  hospital  when  parties  refuse  to  admit  them,  as  in  the  case  of 
lodgers.” 

I might  easily  multiply  similar  extracts,  but  it  seems  unnecessary. 
Let  me  add,  however,  one  remark  in  relation  to  the  fixed  belief  with 
many  city  and  hospital  surgeons,  that  almost  all  severe  cases  of  in- 
jury and  disease  likely  to  require  amputation  are  forwarded  by  the 
rural  practitioner  to  the  city  hospital.  The  great  mass  of  cases  of 
country  limb-amputations  which  I have  collected,  affords  in  itself  a 
strong  answer  to  this  allegation.  Besides,  in  distant  districts  the 
removal  of  severely  injured  or  diseased  patients  for  amputation  to 
city  hospitals  is  a matter  of  impossibility.  And  where  the  practice 
is  possible,  it  is  often  not  at  all  followed.  From  the  medical  gentle- 
men of  Airdrie,  for  example,  and  its  surrounding  villages,  situated 
within  a few  miles  of  the  Boyal  Infirmary  of  Glasgow,  I have 
received  returns  of  about  one  hundred  and  fifty  limb-amputations 
performed  by  them  at  their  patients’  own  homes. 

6.  Evidence  of  increased  Success  in  Amputations 

FROM  INCREASED  EXPERIENCE. 

Out  of  the  2098  amputations  of  the  thigh,  leg,  arm,  and  forearm, 
performed  in  private  provincial  and  country  practice,  and  entered  in 
Table  I.,  226  of  the  patients  died;  or  1 in  every  9'2,  or  10*8  per 
cent.  Of  the  2098  amputations,  1382  were  primary,  traumatic,  or 
performed  for  injuries  or  their  results.  Of  these  1382  cases,  151 
proved  fatal ; or  1 in  9 died,  or  11  in  the  100.  On  the  other  hand, 


COUNTRY  AND  HOSPITAL  AMPUTATIONS. 


325 


716  of  the  2098  amputations  were  secondary,  pathological,  or  for 
disease  and  its  results  ; and  of  these  716  cases,  7 4 proved  fatal ; or 
1 in  every  9*6  died,  or  10‘3  in  every  100. 

Of  the  374  gentlemen  who  have  reported  to  me  these  2098  cases, 
a large  number  have  had  little  opportunity  of  becoming  experienced 
by  much  practice  in  the  performance  of  amputation.  Many  have 
only  been  called  upon  to  have  recourse  to  the  amputating-knife 
once,  twice,  or  thrice,  in  the  whole  course  of  their  lives.  But  in  all 
operations,  the  surgeon  acquires  accumulated  dexterity  and  skill  by 
the  repetition  of  an  operative  proceeding  which,  like  this,  involves 
a combination  of  manual  and  mental  qualities.  It  is  therefore 
natural  to  expect  that  those  practitioners  who  have  performed 
amputation  with  considerable  frequency  should  be  somewhat  more 
successful  in  their  results  than  those  who  have  not  had  the  same 
amount  of  actual  experience.  To  test  on  this  ground  the  relative 
success  of  the  operation  in  the  hands  of  those  provincial  and  rural 
practitioners  who  had  practised  amputation  comparatively  seldom, 
with  those  who  had  practised  it  more  frequently,  I have  taken  out 
of  Table  I.  the  results  of  the  operation  as  observable,  Is^,  in  the 
experience  of  those  medical  men  who  had  performed  amputation 
rarely,  as  only  once,  or  twice,  or  at  most  under  half-a-dozen  times  ; 
2dly,  in  the  experience  of  those  medical  men  who  had  practised 
amputation  six  times  or  oftener  ; and  ^dly,  in  the  experience  of  those 
medical  men  who  had  used  the  amputating-knife  twelve  times  or 
oftener.  These  analytical  results  appear  to  me  of  no  small  interest, 
as  showing  that,  if  the  rural  practitioner  had  as  much  experience  as 
the  Hospital  surgeon,  his  present  great  success  over  the  Hospital 
surgeon  would  be  greater  still ; and  his  proportion  of  deaths  from 
the  major  amputations  would  be  even  less  than  what  the  general 
Table  shows — of  1 death  in  every  9 patients  operated  upon. 

First,  In  the  columns  of  Table  I.  are  contained  the  results  of 
629  limb-amputations,  performed  by  255  practitioners  who  have 
operated  less  than  six  times;  72  of  tliein  liaving  amputated  in  1 
case  only,  82  in  two  cases,  36  in  3 cases,  etc. 

The  following  summary  shows  the  mortality  among  the  indi- 
viduals operated  upon  in  these  629  amputations: — 

Their  total  number  of  cases  was  629  ; of  deaths,  85  ; or  1 in 
every  7 '4  died,  or  13'5  in  every  100. 

Total  number  of  amputations  for  injury,  401  ; of  deaths,  53  ; 
or  1 in  every  7 '2  died,  or  13-2  per  cent. 

Total  number  of  amputations  for  disease,  228  ; of  deaths,  32  ; 
or  I in  every  7T  died,  or  14  per  cent. 


326 


HOSPITALISM. 


Mortality  of  the  Four  Major  Amputations  for  Injuries  and  for  Dis* 
eases  among  255  Practitioners  who  have  amputated  less  than  six 
times. 


Thigh 

cases,  193;  deaths,  44;  or  1 in 

4-4; 

or 

22*7 

Leg 

178;  „ 

32  ; or  1 in 

5*0  ; 

or 

18*0 

Arm 

» , 134  ; „ 

8 ; or  1 in 

16*7; 

or 

6*0 

Forearm 

» 124;  „ 

1 ; or  1 in 

124  ; 

or 

0*8 

Secondly,  I find  in  Table  I.  that  119  gentlemen  practising  in 
the  country  and  provinces  have  had  occasion  to  perform  the  major 
amputations  of  the  limbs  six  times  or  oftener,  with  the  folloAving 
consequences : — 

Total  number  of  cases,  1469  ; of  deaths,  141  ; or  1 in  every 
10*4  died,  or  9 5 in  every  100. 

Total  number  of  amputations  for  injury,  983  ; deaths,  100  ; or 
1 in  every  9*8  died,  or  lOT  in  every  100. 

Total  number  of  amputations  for  disease,  468  ; deaths,  41  ; or 
1 in  every  11'8  died,  or  8 7 in  every  100. 

Mortality  of  the  Four  Mojoi'  Amputations  for  Injuries  and  for  Dis- 
eases among  119  Practitioners  who  have  amputated  six  times  or 
oftener. 


Thigh 

cases,  476  ; 

deaths,  79  ; 

or 

1 

in 

6*0; 

or 

16*5  per  cent. 

Leg 

„ 440  ; 

„ 50; 

or 

1 

in 

00 

00 

or 

11*3 

Arm 

„ 299  ; 

„ 11 ; 

or 

1 

in 

27T  ; 

or 

3*6 

Forearm 

„ 154; 

» 1; 

or 

1 

in 

154  ; 

or 

0*4 

» 

Thirdly,  The  proportion  of  successful  amputations  becomes 
greater  still  when  we  analyse  the  results  of  those  practitioners  who 
have  operated  tw^elve  times  or  oftener.  In  Table  I.  are  to  be  found 
37  returns  in  which  the  number  of  amputations  performed  by  one 
practitioner  was  twelve  or  upwards.  These  37  practitioners  have 
had  occasion  to  perform  the  four  major  amputations  of  the  limbs 
upon  821  patients,  with  the  following  results  : — 

Total  number  of  cases,  821  ; of  deaths,  67  ; or  1 in  every  12’ 2 
died,  or  8T  in  every  100. 

Total  number  of  amputations  for  injury,  561  ; deaths,  46  ; or  1 
in  every  12*2  died,  or  8 ‘2  in  every  100. 

Total  number  of  amputations  for  disease,  260  ; deaths,  21  ; or 
1 in  every  12*4,  or  8 in  every  100. 


COUNTIIY  AND  HOSPITAL  AMPUTATIONS. 


327 


Mortality  of  the  Four  Major  Amputations  for  Injuries  and,  for  Dis^ 

eases  among  37  Practitioners  who  have  operated  twelve  times  or 

oftener. 

Thigh  cases,  260  ; deaths,  35  ; or  1 in  7*4  ; or  13-4  per  cent. 

Leg  „ 250;  „ 25;  or  1 in  10;  or  lO’O  „ 

Arm  „ 179;  „ 6 ; or  1 in  29*8;  or  3'3  „ 

^Forearm  „ 132;  „ 1 ; or  1 in  132;  or  0*7  „ 

The  preceding  three  summaries  of  results  show — 

1.  That,  up  to  a certain  point  at  least,  limb-amputations  become 
more  and  more  successful  in  the  hands  of  rural  and  provincial  prac- 
titioners in  accordance  with  the  experience  which  they  have  had  of 
the  operation. 

2.  That  hence  the  country  limb-amputations  entered  in  Table  I. 
would,  in  all  probability,  have  shown  a still  higher  rate  of  success 
than  they  do  present,  if  they  had  been  all  performed  by  men  who — 
like  city  hospital  surgeons — were  by  experience  accustomed  to  the 
operation.  And, 

3.  That  the  three  successive  summaries  show  how,  with  in- 
creased experience,  there  occurs  not  merely  an  increased  scale  of 
success  in  limb-amputations  taken  as  a whole,  but  also  in  the  dif- 
ferent limb-amputations  taken  individually.  Thus,  for  example, 
amputations  of  the  thigh  are  lost  among  the  three  classes  of  practi- 
tioners in  correspondence  with  the  amount  of  their  experience  in 
the  following  proportions  : 22‘7  per  cent ; 16'5  per  cent ; 13’4  per 
cent ; and  so  on  with  regard  to  the  other  special  amputations. 

7.  On  the  Eesults  of  Limb-Amputations  in  Ppjvate  . 

Practice  in  other  Countries. 

The  statistics  of  limb-amputations  in  country  practice,  collated  in 
Chapter  II.  2,  are  altogether  derived  from  the  experience  of  surgeons 
living  in  the  rural  and  provincial  parts  of  England,  Wales,  and 
Scotland.  No  statistics  of  a similar  kind  have,  so  far  as  I know, 
been  collected  previously  in  Great  Britain  or  elsewhere.  But,  a 
short  time  ago,  I sent  to  my  friend,  Dr.  Nicolaysen  of  Christiania,  a 
copy  of  the  printed  schedule  which  I had  used  here  for  collecting 

^ There  are  only  2 deaths  under  this  heading  in  the  whole  Tables,  1 of  which 
happens  to  be  in  this  class,  and  thus  alters  the  proportion  so  as  to  make  it  look 
worse  than  in  the  other  Tables. 

77 


328 


HOSPITALISM. 


cases  and  their  results  ; and  he  immediately  began  a series  of  similar 
inquiries  regarding  the  danger  and  death-rate  of  amputations  in 
Korway.  The  following  tables,  drawn  up  by  himself,  show  the 
result  of  his  investigations ; and  these  are  important  in  one  respect. 
As  far  as  they  go,  they  confirm  the  conclusion  that  the  average 
death-rate,  after  amputation  of  the  limbs  in  private  country  practice, 
is  about  1 in  9 ; and  they  show  that  the  mortality  is  the  same  in 
Norway  as  in  Great  Britain. 


Results  of  82  Amputations  of  the  Thigh,  Leg,  Arm,  and  Forearm,  in 
Private  Practice  in  Norway. 


Thigh 

cases. 

29; 

deaths,  5 ; 

or 

1 

in 

00 

or 

I— 1 

per 

cent. 

Leg 

30; 

„ 2; 

or 

1 

in 

15; 

or 

6*6 

ft 

Arm 

>» 

8; 

„ 1 ; 

or 

1 

in 

8; 

or 

12*5 

ft 

Forearm 

15; 

„ 1; 

or 

1 

in 

15; 

or 

6-6 

ft 

Total 

cases. 

82; 

deaths,  9 ; 

or 

1 

in 

9-0; 

or 

10*9 

per 

cent. 

Of  these  amputations  there  were.  Primary  or  for  Injury, — 


Thigh 

cases. 

8; 

deaths,  2 ; 

or 

1 

in 

4; 

or  25*0 

per  cent. 

Leg 

9; 

„ 0 

Arm 

)J 

6; 

» 1; 

or 

1 

in 

6; 

or  16*6 

fi 

Forearm 

11 ; 

» 1; 

or 

1 

in 

11; 

or  9*1 

ft 

Total  cases,  34 ; deaths,  4 ; or  1 in  8*5;  or  1T7  per  cent. 


Secondary  or  for  Disease. 


.Thigh 

Leg 

Arm 

Forearm 


cases,  2 1 ; deaths,  3 ; or  1 in  7 ; 
„ 21  ; „ 2 ; or  1 in  10*5  ; 

” ^ i no  deaths. 

» 4 ) 


or  14*3  per  cent, 
or  9*5 


Total  cases,  48  ; deaths,  5 ; or  1 in  9*6  ; or  10*4  per  cent. 


Seeing  that  limb-amputations  are  fatal  in  rural  and  provincial 
private  practice  in  the  proportion  of  1 in  9,  or  less,  let  us  next 
inquire  what,  on  the  contrary,  is  their  death-rate  in  large  and  metro- 
politan hospitals. 


COUNTRY  AND  HOSPITAL  AMPUTATIONS. 


329 


8.  Mortality  of  the  Four  Amputations  of  the  Thigh, 
Leg,  Arm,  and  Forearm,  in  Large  and  Metropolitan 
Hospitals. 

Formerly,  when  writing  of  the  relative  mortality  of  the  four 
major  amputations  of  the  limbs  in  rural  practice  and  in  hospital 
practice,  I ventured  to  lay  it  down  as  a proposition,  that  these  am- 
putations were  about  three  times  more  fatal  in  our  large  and  metro- 
politan hospitals  than  they  were  in  the  country ; for  while  they  were 
fatal  in  country  and  provincial  private  practice  in  the  proportion  of 
1 in  every  9 operated  upon,  they  were  fatal  in  the  large  hospitals  of 
Edinburgh,  Glasgow,  and  London,  in  the  proportion  of  1 in  every  3 
operated  upon.  (See  Medical  Gazette  for  January  16,  1869.) 

To  elucidate  this  important  proposition,  we  shall  therefore  now 
investigate  the  mortality  of  these  four  amputations  in  the  largest 
hospitals  in  Great  Britain ; and  in  doing  so  I shall  use,  as  far  as  I 
have  been  able  to  procure  them,  the  latest  returns  from  these  insti- 
tutions. Our  seven  largest  hospitals  in  this  country  are  the  Eoyal 
Infirmaries  of  Edinburgh  and  Glasgow ; and  in  London,  Guy’s,  St. 
Bartholomew’s,  St.  George’s,  the  London,  and  the  Middlesex  Hos- 
pitals. Each  of  these  institutions  has  upwards  of  300  beds ; most 
of  them  about  500.  St.  Thomas’s  Hospital  when  rebuilt  will,  I 
believe,  be  still  larger.  At  present,  in  its  temporary  quarters,  it 
has  only  about  200  beds.  As  the  problem  refers  to  metropolitan 
hospitals,  we  shall  include  the  statistics  of  other  smaller  London 
hospitals,  as  King’s  College,  St.  Mary’s,  the  Westminster,  the  Eoyal 
Free  Hospital,  etc. 

As  the  whole  of  the  present  inquiry  has  originated  in  questions 
connected  with  the  rebuilding  of  the  Edinburgh  Hospital,  let  us 
begin  with  it. 


I. — Eoyal  Infirmary  of  Edinburgh. 

This  hospital  contains  519  beds.^  The  mortality  in  its  ampu- 
tation cases  has,  at  different  and  distant  dates,  been  published  by 
Dr.  Monro,  Dr.  Eeid,  Dr.  Peacock,  and  others.  Dr.  Fenwick  of 

^ In  these  figures  relative  to  the  number  of  beds  in  different  hospitals,  I have 
chiefly  followed  the  excellent  official  report  of  Dr.  Bristowe  and  Mr.  Holmes  (see 
Sixth  Report  of  the  Medical  Ojfficer  of  the  Privy  Council),  and  Mr.  Churchiira 
Medical  Directory. 


330 


HOSPITALISM. 


London,  when  writing  on  the  mortality  of  amputations  in  1848, 
states  the  number  of  cases  of  the  major  amputations  performed  in 
the  Edinburgh  Infirmary  for  3J  3^ears  to  be  slightly  more  than  1 
in  every  2 (or  more  correctly  1 in  1’96).  For  the  following  Table 
of  its  amputation  statistics  during  the  last  eight  years,  I am  indebted 
to  Mr.  M‘Dougall,  the  highly  esteemed  superintendent  of  the  hospital, 
who  drew  it  up  with  the  permission  of  the  Managers  : — 


Table  IV. — Result  of  the  Four  Amputations  of  the  Thigh,  Leg,  Arm, 
AND  Forearm,  in  the  Royal  Infirmary,  Edinburgh,  from  1859 
TO  1868  inclusive.^ 


FOR  INJURY. 

FOR  disease. 

Year. 

Thigh. 

Le 

o* 

Arm.  1 

Forearm. 

1 Thigh. 

Le< 

D* 

Arm. 

Forearm. 

O c/5 

cd 

No.  of 
Cases. 

w 

O w 

c«  i 

^ C/5 

C/5 

c 2/3 
t ^ 

CO 

rt 

o i 

• c/5 

CO 

a 

No.  of 
Ca.ses. 

"S 

C tc 

CO 

P ^ 

O/ 

Q 

c; 

Q 

a> 

^ ! 

P 

05 

Q 

O ci 

05 

Q 

C rt 

q; 

o 

o 

C d 

P 

1859-60 

3 

3 

7 

1 

0 

0 

0 

0 

13 

1 

0 

0 

0 

0 

1 

0 

1860-61 

4 

3 

5 

1 

3 

1 

4 

0 

9 

1 

3 

0 

1 

0 

0 

0 

1861-62 

10 

7 

7 

5 

2 

0 

3 

0 

19 

3 

2 

0 

1 

0 

2 

0 

1862-63 

4 

4 

10 

5 

1 

0 

7 

0 

12 

6 

5 

1 

1 

1 

2 

1 

1863-64 

6 

3 

6 

3 

3 

3 

2 

0 

21 

10 

5 

3 

2 

0 

5 

2 

1864-65 

5 

5 

3 

2 

3 

1 

7 

2 

14 

4 

3 

2 

1 

1 

5 

4 

1865-66 

12 

8 

5 

4 

4 

3 

3 

1 

11 

3 

5 

1 

0 

0 

2 

0 

1866-67 

10 

9 

8 

3 

4 

3 

8 

1 

14 

10 

1 

0 

1 

1 

1 

O' 

1867-68 

11 

6 

7 

5 

1 

1 

5 

1 

21 

10 

4 

2 

0 

0 

1 

0 

Total  . 

65 

48 

58 

29 

21 

12 

39 

5 

134 

48 

28 

9 

7 

3 

19 

7 

Mortality 
lier  cent. 

73-8 

50-0 

57-1 

12-8 

35-8 

32-1 

42-8 

36-8 

Or  propor- 
tionally 1 in 

1-3 

2-0 

1-7 

7-8 

2-8 

3-1 

2-3 

2-7 

Total  number  of  cases,  871  ; of  deaths,  161  ; or  1 in  every  2‘3 
died,  or  43*3  in  every  100. 

Total  number  of  amputations  for  injury,  183  ; deaths,  94  ; or  1 
in  every  2’0  died,  or  51 ’3  in  every  100. 

Total  number  of  amputations  for  disease,  188;  deaths,  67  ; or 
1 in  every  2 ’8,  or  35*6  in  every  100. 

If  we  combine  together  the  amputations  for  injury  and  for  disease^ 
the  mortality  from  the  different  individual  amputations  during  the 
above  period  in  the  Edinburgh  Infirmary  was  as  folloAvs : — 

Mortcdity  of  the  Individual  A’litpiitaUons. 

Thigh  cases,  199  ; deaths,  96  ; or  1 in  2T  ; or  47*2  per  cent. 

Leg  „ 86  ; „ 38  ; or  1 in  2-2  : or  44-2 

1 Ten  fatal  double  amputations  through  the  continuity  of  the  bones,  alluded 
to  previously  in  Chapter  II.  1,  are  not  included. 


COUNTRY  AND  HOSPITAL  AMPUTATIONS. 


331 


Arm  cases  28  ; deaths,  15  ; or  1 in  1*8  ; or  53-6  per  cent. 

Forearm  „ 58  ; „ 15  ; or  1 in  4*8  ; or  20*7  „ 

II. — Eoyal  Infirmary  of  Glasgow. 

Tliis  great  institution  contains  from  500  to  600  beds.  The 
statistics  of  the  amputations  in  the  Glasgow  Eoyal  Infirmary  at 
difierent  periods  have  been  published  by  Drs.  Lawrie,  Steele,  M‘Ghie, 
Watson,  and  others.  The  following  Table  includes  the  statistics  of 
the  limb-amputations  in  the  hospital  from  1850  to  1868.  These 
returns  are  taken  from  the  published  yearly  reports  of  the  hospital, 
for  access  to  a collection  of  which  I am  indebted  to  the  excellent 
Registrar  of  the  hospital,  Dr.  Thomas  : — 


Table  V.- — Result  of  the  Four  Amputations  of  the  Thigh,  Leg,  Arm, 
AND  Forearm,  in  the  Royal  Infirmary,  Glasgow,  from  1850  to 
1868  INCLUSIVE. 


FOR  INJURY. 

FOR  DISEASE. 

Y^ear. 

1 

Thigh, 

Le 

'S- 

Arm. 

Forearm. 

Thi 

gli- 

Leg. 

Arm. 

Forearm. 

p rt 

o 

j Deaths. 

No.  of 
Cases. 

Deaths. 

No.  of 
Cases. 

Deaths. 

i No.  of 

1 Cases. 

j Deaths. 

No.  of 
Cases. 

j Deaths.  | 

No.  of 
Cases. 

Deaths. 

No  of. 
Cases. 

Deaths. 

No.  of 

1 Cases. 

Deaths. 

1850 

1 

1 

3 

1 

2 

1 

5 

0 

5 

4 

7 

4 

2 

1 

0 

0 

1851 

1 

0 

1 

0 

0 

0 

1 

0 

6 

5 

8 

3 

0 

0 

0 

0 

1852 

0 

0 

1 

0 

2 

0 

5 

0 

5 

2 

6 

3 

1 

0 

4 

1 

1853 

0 

0 

4 

1 

7 

1 

2 

0 

16 

7 

10 

4 

5 

2 

2 

0 

1854 

0 

0 

4 

2 

3 

3 

1 

0 

10 

7 

5 

0 

4 

1 

3 

0 

1855 

3 

1 

2 

2 

2 

1 

2 

0 

5 

3 

10 

1 

0 

0 

1 

0 

1856 

2 

2 

4 

1 

2 

2 

2 

1 

11 

5 

1 

0 

0 

0 

0 

0 

1857 

4 

3 

5 

3 

2 

1 

3 

2 

1 8 

2 

1 

1 

1 

0 

0 

0 

1858 

4 

2 

5 

4 

1 

0 

4 

1 

8 

5 

3 

1 

0 

0 

2 

0 1 

1859 

5 

4 

7 

5 

6 

2 

5 

0 ' 

7 

1 

2 

0 

0 

0 

0 

0 1 

1860 

3 

0 

4 

3 

9 

1 

4 

0 ' 

8 

2 

3 

2 

3 

0 

0 

1861 

7 

4 

9 

6 

3 

2 

6 

2 ! 

14 

7 

6 

3 

2 

1 

2 

0 ! 

1862 

12 

4 

9 

2 

6 

2 

3 

0 ' 

7 

0 

2 ■ 

0 

3 

0 

1 

0 1 

1863 

13 

10 

3 

1 

6 

2 

5 

1 I 

14 

4 

3 

0 

0 

0 

0 

0 ' 

1864 

7 

4 

9 

3 

9 

2 

8 

2 i 

9 

3 

4 

1 

1 

1 

0 

0 I 

1865 

8 

6 

7 

6 

14 

2 

6 

0 

12 

4 

1 

0 

0 

0 

0 

0 ! 

1866 

18 

12 

7 

4 

12 

6 

2 

0 

4 

1 

5 

3 

0 

0 

3 

0 i 

1867 

3 

1 

8 

5 

6 

5 

2 

0 

13 

2 

3 

0 

0 

0 

0 

0 

1868 

9 

6 

1 

1 

9 

5 

0 

0 

15 

4 

2 

1 

1 

0 

1 

0 

Total  . 

100 

60 

93 

50 

101 

38 

66 

9 

177 

68 

82 

27 

23 

6 

19 

i 1 

Mortality 
per  ceiit. 

60-0 

53-7 

37-6 

13-6 

38-4 

329 

26-0 

5- 

2 

Or  1 in 

1-6  ! 

1-8 

~2-6~ 

7-3 

3-0 

— g-.Q- 

3-8  1 

19-0 

Total  number  of  cases,  661;  of  deaths,  259.  Hence  1 in  every 
2'5  died,  or  39 T in  every  100. 


332 


HOSPITALISM. 


Total  number  of  amputations  for  injury,  360;  deaths,  157:  or  1 
in  every  2 ’3  died,  or  43*6  in  every  100. 

' Total  number  of  amputations  for  disease,  301;  deaths,  102;  or 
1 in  every  2*9  died,  or  33*8  in  every  100. 

Mortality  of  the  Four  Major  Amputatioiis,  corabining  together 
Operations  for  Injuries  and  Operations  for  Diseases. 

Thigh  cases,  277  ; deaths,  128  ; or  1 in  2*1 ; or  46*2  per  cent. 

Leg  „ 175;  „ 77;  or  1 in  2*2;  or  44*0  „ 

Arm  „ 124;  „ 44;  or  1 in  2*8 ; or  35*4  „ 

Forearm  „ 85;  „ 10;  or  1 in  8*5;  or  11*7  „ 

III. — St.  Bartholomew’s  Hospital,  London. 

Of  the  London  hospitals,  this  is  the  oldest  in  its  foundation,  and 
has  always  been  held  in  high  esteem.  It  contains  650  beds.  I am 
obliged  to  Mr.  Alfred  Willett,  the  Surgical  Registrar  to  the  hospital, 
for  copies  of  the  official  statistical  reports,  and  for  the  following 
Table  of  the  limb-amputations  performed  there  since  1863,  with 
their  results. 


Table  VI. — Results  of  the  Four  Amputations  op  the  Thigh,  Leg, 
Arm,  and  Forearm,  in  St.  Bartholomew’s  Hospital,  London, 
FROM  1863  TO  1868  inclusive. 


FOR  INJURY. 

FOR  DISEASE. 

Year. 

Thij 

Leg. 

Arm. 

Forearm. 

Thi 

gli- 

Leg. 

1 Arm. 

1 

Forearm. 

c 

W 

x: 

CS 

o i 
6 2 

o i 

o 5 

03 

x: 

^ • 

O M 

d S 

03* 

"c? 

o “ 

O ^ 

o'i 
6 S 

03 

a 

o M 

d 2 

cS 

6 2 

03* 

Q 

c 

Q 

Q 

SCO 

Q 

Q 

Q 

O 

1863 

7 

5 

10 

4 

3 

1 

4 

2 

22 

10 

5 

0 

1 

0 

1 

0 

1864 

4 

3 

7 

5 

10 

3 

3 

0 

21 

8 

10 

4 

1 

0 

3 

0 

1865 

7 

3 

4 

4 

2 

0 

5 

0 

14 

7 

14 

6 

5 

0 

3 

0 

1866 

4 

2 

6 

1 

3 

0 

2 

0 

5 

1 

3 

2 

2 

0 

1 

0 

1867 

2 

1 

4 

1 

1 

0 

2 

0 

9 

4 

2 

1 

3 

0 

1 

0 

1868 

1 

1 

8 

6 

2 

0 

7 

1 

13 

7 

10 

3 

3 

0 

2 

0 

Total . . 

25 

15 

39 

21 

21 

4 

23 

3 

84 

si 

44 

16 

15 

0 

11 

0 

Mortality 
per  cent. 

60*0 

54-0 

19 

13-0 

44*0 

36-3 

Or  i)ropor- 
tionally  1 in 

1*6 

1*8 

5*2 

7*6 

2-2 

2*7 

Total  number  of  cases,  262  ; of  deaths,  96  ; or  1 in  every  2*7,  or 
36*6  in  every  100. 

Total  number  of  amputations  for  injury,  108  ; of  deaths,  43  ; or 
1 in  every  2*5,  or  40  in  every  100. 


COUNTRY  AND  HOSPITAL  AMPUTATIONS. 


333 


Total  number  of  amputations  for  disease,  154;  of  deaths,  53;  or 
1 in  every  2'9,  or  34*4  in  every  100. 

If  we  combine  together  the  amputations  for  injury  and  for  dis- 
ease, the  mortality  from  the  individual  amputations  during  the  above 
period  in  St.  Bartholomew’s  Hospital  is  as  follows: — 


Mortality  from  the  Individual  Amputations. 


Thigh  cases. 

109  ; 

deaths. 

52; 

or  1 in  2T,  or  47*7  per  cent. 

Leg 

83; 

)» 

37; 

or  1 in  2*2,  or  44*5  „ 

Arm  „ 

36; 

i; 

or  1 in  9,  or  11*1  „ 

Forearm  „ 

34; 

3; 

or  1 in  11,  or  8*8  „ 

IV. — The  London  Hospital,  Whitechapel. 

The  London  Hospital  is,  according  to  Dr.  Bristowe  and  Mr. 
Holmes,  “ the  greatest  surgical  institution  in  the  metropolis.”  It 
contains  500  beds,  of  which  350  are  devoted  to  surgical  cases.  For 
the  amputation  returns  for  the  year  18G2  I am  indebted  to  the  re- 
port of  Dr.  Bristowe  and  Mr.  Holmes  ; and  for  the  years  1863,  4,  5, 
and  6,  to  the  summaries  given  in  the  four  published  volumes  of  the 
Clinical  Lectures  and  Reports  of  the  Hospital.  Those  of  the  last  two 
years,  1867-8,  have  been  furnished  me  by  Mr.  Jonathan  Hutchison, 
Surgeon  to  the  Hospital,  and  Lecturer  on  Surgery  at  its  Medical 
School. 


Table  VII. — Eesults  op  the  Four  Amputations  of  the  Thigh,  Leg, 
Arm,  and  Forearm,  in  the  London  Hospital,  from  1862  to  1868 
inclusive. 


FOR  INJURY. 

FOR  DISEASE. 

Year. 

Thi 

gh. 

Leg, 

Arm. 

Forearm. 

Thi 

gh. 

Le 

Arm. 

Forearm. 

Cm  • 

o ^ 

Deaths. 

i No.  of 
Cases. 

Deatlis. 

1 No.  of 
Cases. 

Deaths. 

1 No.  of 

1 Cases. 

Deaths. 

No.  of 
Cases. 

Deaths. 

No.  of 
Cases. 

Deaths. 

No.  of 
Cases. 

Deaths. 

No.  of 
Cases. 

Deaths. 

1862 

4 

2 

14 

9 

7 

5 

0 

0 

9 

3 

1 

1 

1 

0 

0 

0 

1863 

4 

4 

7 

5 

6 

3 

0 

0 

5 

1 

5 

0 

0 

0 

3 

0 

1864 

9 

8 

5 

5 

5 

3 

3 

0 

7 

3 

4 

2 

0 

0 

1 

1 

1865 

9 

7 

7 

6 

4 

1 

0 

0 

11 

6 

3 

2 

0 

0 

0 

0 

1866 

5 

2 

4 

3 

6 

2 

3 

0 

9 

4 

2 

2 

0 

0 

0 

0 

1867 

3 

3 

7 

2 

2 

1 

2 

0 

15 

4 

3 

1 

1 

0 

0 

0 

1868 

4 

2 

1 

0 

1 

0 

2 

0 

12 

2 

4 

1 

3 

0 

1 

0 

Total . . 

38 

28 

45 

30 

31 

15 

10 

0 

68 

23 

22 

9 

5 

0 

5 

1 

Moi-tality 
per  cent. 

73-6 

66-6 

48-4 

33-8 

41 

20 

Orpropor- 

1 tionally  1 in 

1-3 

1*5 

2 

1 2-9 

1 2*4 

5 

334 


HOSPITALISM. 


Total  number  of  cases,  224  ; of  deaths,  lOG  ; or  1 in  every  2T, 
or  47 ‘3  in  every  100. 

Total  number  of  amputations  for  injury,  124  ; of  deaths,  73  ; or 
1 in  every  T7,  or  5 8 ’8  in  every  100. 

Total  number  of  amputations  for  disease,  100  ; of  deaths,  33  ; or 
1 in  every  3,  or  33  in  every  100. 

If  we  combine  together  the  amputations  for  injury  and  for  disease, 
the  mortality  from  the  individual  amputations  in  the  London  Hospital 
is  as  follows: — 

Mortality  of  Individual  Amputations. 

Thigh  cases,  106  ; deaths,  51  ; or  1 in  2'0  ; or  48T  per  cent. 
Leg  „ G7 ; „ 39 ; or  1 in  L7 ; or  58-2  „ 

Arm  „ 36;  „ 15;  or  1 in  2’4 ; or  41-6  „ 

Forearm  „ 15;  „ 1;  or  1 in  15;  or  6 6 „ 

V. — Guy’s  Hospital,  London. 

This  institution  can  make  up  580  beds.  My  friend.  Dr.  Steele, 
the  very  able  superintendent  of  the  hospital,  has  for  many  years  past 
kept  up,  among  other  things,  its  Statistical  Register  with  most  ex- 
emplary care  and  accuracy.  I am  under  obligations  to  him  for  the 
data  in  the  following  Table: — 


Table  VIII. — Results  of  the  Four  Amputations  of  the  Thigh,  Leg, 
Arm,  and  Forearm,  in  Guy’s  Hospital,  London,  from  1861  to 
1868  INCLUSIVE. 


FOR  INJURY. 

! FOR  DISEASE. 

Thiffh. 

Lepc. 

Arm. 

Forearm. 

Thi 

gh. 

Leg. 

Arm. 

Forearm. 

Tear. 

• 

CO 

tA 

c*-. 

cd 

• 

(A 

A 

Cm  . 

tA 

A 

O CO 
0) 

ti 

'q  CO 

• 

% 

1 No.  0 
1 Cases 

rt 

1 No.  0 
1 Cases 

o y? 

<D 

CO 

Cj 

O 

o w 

1 No.  0 
1 Cases 

o’  rt 

Q 

O ci 

a> 

Q 

O 

<u 

Q 

0) 

Q 

>P  ^ 

Q 

O rt 

0) 

Q 

O) 

p 

1861 

6 

2 

2 

0 

6 

2 

0 

0 

8 

2 

6 

0 

1 

1 

3 

1 

1862 

7 

3 

8 

4 

1 

0 

4 

0 

7 

4 

6 

1 

2 

0 

0 

0 

1863 

7 

4 

4 

3 

3 

0 

0 

0 

i 12  1 

1 4 

10 

2 

1 

0 

0 

0 

1864 

5 

4 

11 

6 

1 

1 

1 

1 

4 

4 

1 

1 

1 

0 

0 

1865 

7 

5 

12 

6 

4 

2 

1 

1 

I 7! 

4 

6 

1 

i 1 

2 

1 

1866 

4 

2 

8 

6 

5 

2 

3 

1 

; 10  j 

1 

6 

1 

1 ! 

1 1 

1 

0 

1867 

5 

4 

8 

2 

9 

3 

2 

1 

14  ! 

5 

9 

3 

3 1 

1 

1 

0 

1868 

5 

2 

0 

0 

2 

2 

4 

2 

14  1 

3 

2 

0 

1 

0 

1 

0 

Total  . . 

46 

26 

53  ! 27 

31 

12 

15 

6 

83  i 

27 

49 

9 

13 

5 

~F 

2 

Mortality 
per  cent. 

56-5 

51 

38-7 

40 

1 32-5 

18 

38-4 

25 

Or  propor- 
tionally 1 in 

' 1.-8 

1-9 

2-6 

2-5 

! 3 

5-4 

2-6 

4 

Total  number  of  cases,  298  ; of  deaths,  114  ; or  1 in  every  2 ’6 
or  38*2  in  every  100. 


COUNTRY  AND  HOSPITAL  AMPUTATIONS. 


335 


Total  number  of  amputations  for  injury,  145;  of  deaths,  71  ; or 
1 in  every  2,  or  49  in  every  100. 

Total  number  of  amputations  for  disease,  153  ; of  deaths,  43  ; or 
1 in  every  3‘5,  or  28  in  every  100. 

If  we  combine  together  the  amputations  for  injury  and  for  disease, 
the  mortality  from  the  individual  amputations  in  Guy’s  Hospital  is 
as  follows  : — 

Mortalit])  of  the  Individual  Amputations. 

Thigh  cases,  129  ; deaths,  53  ; or  1 in  2 '4  ; or  4 TO  per  cent. 


Leg 

» 102;  „ 

36  ; or  1 in  2 '8  ; or  35‘3 

Arm 

44  • 

» ) » 

17  ; or  1 in  2’6  ; or  38-6 

Forearm 

23  • 

) V 

8 ; or  1 in  2-8  ; or  34-7 

VI. — St.  George’s  Hospital,  London. 

This  hospital  contains  350  beds  ; 200  of  which  are  set  aside  for 
surgical  cases.  lake  all  the  large  London  hospitals,  the  edifice 
consists  of  four  flats  or  storeys.  For  the  following  data,  in  regard  to 
the  limb-amputations  j^erformed  in  St.  George’s  during  the  last  five 
years,  I stand  indebted  to  the  kindness  of  Mr.  Leigh,  Ilegistrar  to 
the  hospital. 


Table  IX. — Results  op  the  Four  Amputations  of  the  Thigh,  Leg, 
Arm,  and  Forearm,  in  St.  George’s  Hospital,  London,  from  1864 
TO  1868. 


FOR  INJURY. 

FOR  DISEASE. 

Thi] 

5h. 

Le 

o* 

Ann. 

Forearm. 

Thigh. 

Le 

g. 

Arm.  1 

Forearm. 

Year. 

c g 

a: 

Cw  • 
O M 
a; 

w 

o w 

22 

75 

o w 
o 

C/5 

23 

o 75 
CJ 

75 

s' 

22 

O S 

c3 

(V 

O 

d I 

<D 

• ^ 

O 

a> 

o rt 

dg 

rt 

CJ 

^ 75 

s 

d ^ 

a 

o 

a 

Q 

Q 

ft 

Q 

Q 

Q 

1864 

1 

0 

4 

0 

0 

0 

1 

0 

7 

2 

7 

2 

0 

0 

2 

0 

1865 

0 

0 

0 

0 

4 

2 

1 

0 

12 

4 

7 

2 

4 

0 

0 

0 

1866 

3 

2 

0 

0 

0 

0 

0 

0 

13 

7 

13 

3 

1 

1 

0 

0 

1867 

0 

0 

1 

0 

1 

0 

0 

0 

11 

7 

8 

2 

2 

2 

1 

0 

1868 

1 

1 

3 

2 

2 

2 

0 

0 

11 

5 

1 

1 

1 

1 

3 

1 

Total  . . 

5 

3 

8 

2 

~7~ 

4 

2 

0 

54 

! 25 

36 

10 

8 

4 

6 

1 

Mortality 
per  cent. 

60 

25 

57 

46-3 

27-7 

50 

16-6 

Or  propor- 
tionally 1 in 

1-6 

4 

1-8 

j 2-1 

3-6 

! ^ 

6 

Total  number  of  cases,  126  ; of  deaths,  49  ; or  1 in  every  2*5,  or 
38*8  in  100. 


Total  number  of  amputations  for  injury,  22  ; of  deaths,  9 ; or  1 
in  every  2 ‘4,  or  41  in  every  100. 

Total  number  of  amputations  for  disease,  104  ; of  deaths,  40  ; or 
1 in  every  2 ’6,  or  CS‘4  in  every  100. 


336 


HOSPITALISM. 


If  we  combine  together  the  amputations  for  injury  and  for  disease, 
the  mortality  from  the  individual  amputations  in  St.  George’s 
Hospital  is  as  follows  : — 

Mortality  of  the  Individual  Amputations. 

Thigh  cases,  59  ; deaths,  28  ; or  1 in  2T  ; or  47 ’4  per  cent. 
Leg  „ 44 ; „ 12 ; or  1 in  3-6 ; or  27'2  „ 

Arm  „ 15 ; „ 8 ; or  1 in  1 '8  ; or  53‘3  „ 

Forearm  „ 8 ; „ 1 ; or  1 in  8 ; or  12-5  „ 

VII. — Eesults  of  Limb- Amputations  in  Nine  Metropolitan 
Hospitals. 

I have  been  kindly  furnished  by  Mr.  Arnott,  Mr.  Bell,  Mr. 
Murphy,  Mr.  Holt,  and  Dr.  Black,  with  the  amputation  stati.stics  of 
five  other  London  hospitals,  in  addition  to  those  of  the  four  chief 
metropolitan  hospitals  adduced  in  the  four  preceding  Tables.  But 
as  these  five  hospitals  are  all  smaller,  and  hence  their  returns  not 
so  important,  nor  in  some  respects  so  complete  or  continuous,  it  is 
unnecessary  perhaps  to  print  them  at  length.  In  the  succeeding 
Table,  therefore,  I will  take  the  liberty  of  conjoining  them  and  the 
four  preceding  hospital  returns — so  as  thus  to  have  a general  and 
connected  view  of  the  mortality  attendant  upon  limb-amputations 
in  these  nine  metropolitan  hospitals,  taken  either  individually  or  as 
a whole. 


Table  X. — Latest  Results  of  the  Four  Amputations  of  the  Thigh 
Leg,  Arm,  and  Forearm,  in  Nine  London  Hospitals. 


i 

FOR  INJURY. 

FOR  DISEASE. 

Name  of  Hospital. 

Years  of 
Observa- 
tion. 

Thigh. 

Le 

•s* 

Arm. 

Fore- 

arm. 

Thi 

I 

Leg. 

Arm. 

Fore- 

arm. 

Cases. 

Deaths.  1 

Cases,  j 

Deaths.  | 

m 

a> 

c/5 

c3 

O 

Deaths.  | 

Cases.  1 

Deaths.  | 

Cases.  1 

1 1 

Deatiis. 

OT 

C/5 

c3 

o 

ai 

Q 

1 Cases. 

1 Deaths. 

1 Ca.ses. 

1 Deaths. 

St.  Bartholomew’s 

186.3-68 

25 

15 

39 

21 1 

21 

4 

23 

3 

84 

37 

; 44 

16 

15 

0 

11 

0 

St.  George’s  . . 

1864-68 

5 

3 

8 

21 

27i 

7 

4 

2 

0 

54 

25 

36 

10 

8 

4 

6 

1 

Guy’s  .... 

1861-68 

44 

26 

53 

30 

12 

15 

6 

83 

27 

49 

9 

13 

5 

5 

2 

London  .... 

1862-68 

38 

28 

45 

30 

31 

15 

110 

0 

68 

23 

22 

9 

5 

0 

5 

1 

Middlesex  . . . 

1867-68 

] 

0 

4 

3 

1 

1 

0 

0 

0 

0 

0 

0 

1 

1 

1 

1 

King’s  College  . . 

1863-68 

1 

1 

1 

1 

0 

0 

1 

0 

14 

5 

5 

1 

1 

1 

4 

2 

Royal  Free  . . . 

1862-68 

9 

6 

23 

15 

6 

2 

8 

1 

6 

1 

2 

0 

1 

1 

1 

0 

Westminster  . . 

1861-67 

14 

9 

5 

3 

0 

0 

0 

0 

5 

4 

14 

7 

4 

1 

3 

0 

St.  Mary’s  . . . 

1868 

2 

0 

1 

1 

0 

5 

1 

6 

1 

1 

1 

1 

0 

0 

1 

0 

Total . 

139 

88 

179102 

97 

38 

64 

11 

320 

123'l73  53 

48'l3 

37 

7 

Mortality  per  cent  . . 

63-3 

57 

39-1 

17-1 

38-4 

35-7 

27*0 

18-9 

Or  proportionally  1 in  . . 

1-6 

1-7 

2-5 

5-8 

2-6 

1 3 

•2 

3-7 

5-2 

COUNTRY  AND  HOSPITAL  AMPUTATIONS. 


337 


Total  number  of  cases,  1057  ; of  deaths,  435  ; or  1 in  every  2*4 
died,  or  4T1  in  every  100. 

Total  number  of  amputations  for  injury,  479  ; deaths,  239  ; or 
1 in  every  2*0  died,  or  50  in  every  100. 

Total  number  of  amputations  for  disease,  578  ; deaths,  196  ; or 
1 in  every  2*9  died,  or  33*9  in  every  100. 

If  we  combine  together  the  amputations  for  injury  and  for 
disease,  the  mortality  from  the  individual  amputations  in  the  above- 
mentioned  London  hospitals  was  as  follows  : — 

Mortality  of  the  Individual  Amputations. 

Thigh  cases,  459;  deaths,  211  ; or  1 in  2‘1  ; or  46’0  per  cent. 

Leg  „ 352  ; „ 155;  or  1 in  2*2;  or  44*0  „ 

Arm  „ 145  ; „ 51  ; or  1 in  2*8  ; or  35*1  „ 

Forearm,,  101  ; „ 18;  or  1 in  5*5;  or  17*8  „ 

VIII. — Eleven  Large  and  Metropolitan  British  Hospitals. 

If  we  throw  together  into  one  table  the  data  spread  over  the 
preceding  seven  tables,  including  together  the  amputation  statistics 
of  the  Edinburgh  and  Glasgow  Infirmaries,  and  of  nine  of  the  leading 
London  Hospitals,  the  result  is  as  follows : — 

Table  XL — Results  of  the  Four  Amputations  of  the  Thigh,  Leg, 
Arm,  and  Forearm,  in  Eleven  Large  and  Metropolitan  Hospi- 
tals ; all  Amputations  through  the  Joints  being  excluded. 


FOR 

, INJURY. 

FOR  disease. 

Hospitals. 

Thigh. 

Leg. 

Arm. 

Fore- 
arm. 1 

Thigh. 

Leg. 

Arm. 

Fore 

arm. 

W 

0) 

CO 

o 

1 Deaths. 

j Cases. 

Deaths. 

1 Cases. 

1 Deaths. 

1 Cases. 

CO 

'S 

p 

j Cases. 

Deatlis. 

1 

CO 

CO 

c3 

O 

Deaths.  1 

aa 

cc 

ci 

P 

Deaths.  I 

S 

c; 

O 

1 ^ 

C3 

■V 

Edinburgh  Infirmary 

65 

48 

58 

29 

21 

12 

39 

5 

134 

48 

28 

9 

7 

3 

19 

7 

Glasgow  Infirmary  . 

100 

60 

93 

50 

101 

|38 

66 

9 

177 

68 

82l27 

23 

6 

19 

1 

Nine  Metropolitan  Hos- 
pitals   

139 

88 

179 

102 

97 

1 

38 

64 

11 

320 

123 

I73j53 

48 

13 

37 

7 

Total  . . 

304 

196 

330181 

219  88 

169i 

l25 

631  239 

283'S9 

78 

22 

j75  15 

Mortality  per  cent  . 

64-4 

54-8 

40-1 

14-8 

37.8 

31-4 

28 

1-2 

20 

Or  proportionally  1 in  . 

1-5 

1-8 

2-5 

6-7  ! 

2-6 

3 

*2 

35 

! 

5 

Total  number  of  cases,  2089  ; of  deaths,  855  ; or  1 in  2*4,  or  41 
per  cent 


338 


HOSPITALISM. 


Total  number  of  amputations  for  injury,  1022  ; of  deaths,  490  ; 
or  1 in  2 T,  or  48  per  cent. 

Total  number  of  amputations  for  disease,  1067  ; of  deaths,  365  ; 
or  1 in  2’9,  or  34-2  per  cent. 

Mortality  of  Individual  AmiDuiations. 

Thigh  cases,  935  ; deaths,  435  ; or  1 in  2T,  or  46*5  per  cent. 

Leg  „ 613  ; „ 270  ; or  1 in  2*2,  or  44*0  „ 

Arm  „ 297  ; „ 110  ; or  1 in  2-7,  or  37‘0  „ 

Forearm  ,,  244  ; „ 40  ; or  1 in  6-0,  or  16-4  „ 

Mortality  from  the  Amindations  for  Injury  in  the  Edinburgh  and 
Glasgow  Infirmaries^  and  in  Nine  London  Hospitals. 


Thigh  cases,  304  ; 

deaths,  196  ; 

or  1 in  1’5,  or  64’4 

per  cent. 

I, eg  „ 330  ; 

181  ; 

or  1 in  P8,  or  54’8 

)> 

Arm  „ 219; 

5J 

88  ; 

or  1 in  2*3,  or  40T 

» 

Forearm  „ 169  ; 

25; 

or  1 in  6*7,  or  14-7 

Mortality  from  the  Amputations  for 

Disease  in  the  same 

Hospitals. 

Thigh  cases,  631  ; 

deaths,  239  ; 

or  1 in  2*6,  or  37*8 

per  cent. 

Leg  „ 283  ; 

5J 

89  ; 

or  1 in  3*1,  or  31*4 

Arm  „ 78; 

» 

22; 

or  1 in  3*5,  or  28*2 

ff 

Forearm  „ 75  ; 

15; 

or  1 in  5*0,  or  20*0 

» 

9.  The  Proportionate  Death-rate  and  the  Excess  of  Mor- 
tality OF  Limb-Amputations  in  large  and  Metropolitan 
Hospitals,  as  compared  with  Country  Practice. 

The  total  number  of  limb-amputations  collected  from  private 
country  and  i:)rovincial  practice  contained  in  Table  1.  amounts  to 
2098.  On  counting  up  the  limb-amputations  collected  from  eleven 
large  and  metropolitan  hospitals,  and  contained  in  Table  XL,  the 
total  number  happens  accidentally  to  be  very  nearly  the  same,  for 
it  amounts  to  2089. 

The  whole  collected  number  operated  upon  is  thus  nearly  similar 
in  hospital  practice  and  in  rural  practice.  But  the  results  as  to 
the  relative  number  of  lives  lost  in  these  two  types  or  places  of 
practice  is  immensely  different. 

After  the  2098  limb-amputations  in  the  country,  226  of  the 
patients  died.  After  the  2u89  limb-amputations  in  eleven  large  and 
metropolitan  hospitals,  855  of  the  patients  died. 


COUNTRY  AND  HOSPITAL  AMPUTATIONS. 


339 


The  mortality  after  limb-amputations  in  the  country  is  thus  1 in 
9 ’2  (see  Chapter  I.  2),  and  after  limb-amputations  in  large  and  metro- 
politan hospitals  1 in  2 '4  (see  Chapter  11.  8).  Hence  the  number  that 
die  after  these  operations  is  in  such  hospital  practice,  when  compared 
with  rural  practice,  nearly  FOUR  TIMES  gp.eater. 

But  the  experienced  country  surgeon  loses — as  we  have  seen 
(see  Chapter  II.  6) — only  1 in  every  12 ’4  of  his  patients  upon  whom 
he  performs  limb -amputation.  Hence  the  experienced  country 
surgeon  operating  upon  his  patients  in  poor  cottages  and  villages  is 
— as  compared  with  the  experienced  city  surgeon,  operating  upon 
his  patients  in  rich  and  magnificent  hospitals — five  times  more 
SUCCESSFUL. 

In  some  minor  amputations — and  hence,  I believe,  in  other 
minor  operations  also — the  contrast  is  still  more  marked  between 
the  success  of  amputation  in  country  practice  and  in  the  practice  of 
large  hospitals.  In  country  practice,  after  amputation  of  the  fore- 
arm, 2 died  out  of  377  cases,  or  1 in  every  188  operated  on.  In 
eleven  large  and  metropolitan  hospitals,  out  of  244  cases  of  amputa- 
tion of  the  forearm,  40  died,  or  1 in  every  G operated  on.  Hence, 
according  to  these  data,  the  death-rate  in  hospital  practice  was,  as 
compared  with  the  death-rate  in  rural  practice  in  this  individual 
operation,  thirty  times  greater. 

The  tremendous  differences  between  the  two  practices  may,  per- 
haps, be  more  pointedly  and  simply  stated  thus : — 

Out  of  2089  amputations  in  hospital  practice,  855  died  ; 

Out  of  2098  amputations  in  country  practice,  226  died  ; 

Giving  an  excess  to  hospital  practice  of  629  deaths. 

This  excess,  in  about  2100  limb-amputations,  of  629  deaths  in 
hospital  practice  as  compared  with  rural  practice — in  our  palatial 
hospitals  as  compared  with  our  rural  villages  and  cottages — in  large 
wards  as  compared  with  isolated  rooms — is  certainly  much  greater 
and  more  pronounced  than  I myself  expected  wdien  I began  the 
present  inquiry.  But  must  the  calling  of  this  dismal  death-roll  still 
go  on  unchallenged  and  unchecked  1 Shall  this  pitiless  and  deli- 
berate sacrifice  of  human  life  to  conditions  which  are  more  or  less 
preventable,  be  continued  or  arrested  ? Do  not  these  terrible  figures 
plead  eloquently  and  clamantly  for  a revision  and  reform  of  our 
existing  hospital  system  ? 


340 


HOSPITALISM  : 


CHAPTER  III. 

SOME  PROPOSITIONS  ON  HOSPITALISM,  BASED  ON  STATISTICS  OF 
COUNTRY  AND  HOSPITAL  AMPUTATIONS. 

Proposition  I. — The  aggregation  or  isolation  of  patients  regulates, 
in  a marked  degree,  the  results  of  operations,  etc.,  upon  them. 

If  we  take,  for  instance,  as  Mr.  Holmes^  and  others  have  done, 
the  mortality  accompanying  the  four  major  amputations  of  the 
limbs — viz.  amputation  of  the  thigh,  leg,  arm,  and  forearm — as  a 
test  of  the  salubrity  of  the  different  hospital  systems  and  conditions 
under  which  patients  may  be  placed,  the  results  shown  by  the  ampu- 
tation statistics  which  I have  collected  appear  to  me  to  open  up 
some  new  views  as  to  hospital  and  domestic  hygiene.  I have  col- 
lated about  7000  limb-amputations  performed  of  late  years  in  Great 
Britain,  in  hospital  and  private  practice.  I have  already  given  the 
details  of  above  2000  cases  in  private  country  practice,  and  above 
2000  cases  in  the  practice  of  our  large  and  metropolitan  hospitals. 
Nearly  3000  cases  which  have  been  reported  to  me  from  provincial 
hospitals — large  and  small — require  to  be  reduced.  The  general 
outline  of  the  whole  inquiry  may,  as  it  at  present  stands,  be  shown 
in  this  table  ; — 

Table  XII. — Proportionate  Mortality  of  Limb- Amputations  in 
Great  Britain,  as  regulated  by  the  Size  of  the  Hospital  and 
THE  Degree  of  Aggregation  or  Isolation  in  which  the  Patients 

ARE  PLACED. 


Death-rate. 
1 in  24  die 
1 in  4 ,, 

1 in  54  ,, 

1 in  7 ,, 


1.  In  hospitals  from  300  beds  to  600 

2.  In  hospitals  from  100  beds  to  300 

3.  In  hospitals  from  25  beds  to  100 

4.  In  cottage  hospitals  under  25  beds 


5.  In  isolated  rooms  in  country  practice 


1 in  9 ,, 


1 The  Report  of  Mr.  Holmes  and  Dr,  Bristowe  is  embodied  in  one  of  the 
Government  Blue-books  for  1863,  entitled  Sixth  Report  of  the  Medical  Officer  of 
the  Privy  Council.  Mr.  Simon  has  written,  as  usual,  for  the  volume,  a very  able 
preface  or  commentary. 


PROPOSITIONS  ON. 


341 


These  few  figures  teach  a lesson  of  vast  import  in  relation  to 
hospital  hygiene ; and  yet  they  seem  to  discourse  so  plainly  as  to 
require  no  comment. 

Mr.  Holmes  started  apparently,  in  his  inquiry  and  reasoning, 
upon  the  opposite  idea,  that  our  present  palatial  hospital  system  is 
comparatively  perfect ; and  that  more  especially  the  size  of  an 
hospital  does  not  affect  its  success  or  unsuccess  in  the  treatment 
and  recovery  of  the  patients  admitted.  He  seems  to  be  swayed  and 
influenced  throughout  by  this  fundamental  error.  Thus,  in  his 
official  Eeport,  he  observes : “ If  all  the  subordinate  parts  of  the 
hospital  have  been  well  constructed  for  ventilation  and  space,  and  all 
are  kept  in  perfect  order  by  drainage  and  cleanliness  — cleanliness, 
that  is,  of  the  patients  and  their  bedding,  as  well  as  of  all  parts  of 
the  building  — we  have  no  hesitation  in  saying  that  the  size  of  the 
hospital  is  a matter  of  absolute  indifference ; whether  it  contains  a 
hundred  patients  or  a thousand  does  not  appear  to  exercise  the  least 
influence  on  the  health  of  any  individual  in  the  hospital.” 

In  a paper  in  the  Lancet^  Mr.  Holmes,  in  a similar  spirit, 
remarks : “ With  respect  to  small  and  large  hospitals,  I have 

searched  in  vain  for  any  evidence  that  there  is  any  difference  in 
their  salubrity,  providing  the  cases  are  the  same  and  “ the  alleged 
greater  salubrity  of  cottage  hospitals,  or  of  small  city  hospitals,  as 
compared  with  large  ones,  rests  on  no  evidence  whatever.”  ^ 

But  while  Mr.  Holmes  thus  regrets  the  want  of  any  evidence  to 
show  the  salubrity  of  small  as  compared  with  large  hospitals,  the 
very  evidence  which  he  thus  professes  to  lack  existed  in  his  own 
elaborate  Eeport  of  the  hospitals  which  he  visited  under  his  com- 
mission, and  whose  statistics  he  published  in  his  official  Eeport. 
He  has  so  far  misinterpreted  his  own  data  in  his  own  Eeport.  He 
has  given  a table  of  the  amputations  in  upwards  of  sixty  British 
hospitals.  Seventeen  of  these  hospitals  contained  100  beds  or 
less,  and  the  others  from  100  to  600  beds.  The  following  Table 
presents  the  relative  mortality  accompanying  limb-amputations  in 
these  two  classes  of  hospitals,  and  shows  the  death-rate  in  the  hospi- 
tals under  100  beds  to  be  even  smaller  than  my  data  indicate. 

Table  XIII. — Mortality  of  Limb- Amputations  as  regulated  by  the 
Size  of  the  Hospital,  from  the  Data  published  in  Mr.  Holmes’s 
Official  Eeport  (1863). 

Size  of  Hospital.  Death-rate. 

1.  In  hospitals  from  100  to  600  beds  . . . 1 in  4 die. 

2.  In  hospitals  under  100  beds  . . . . 1 in  6 ,, 


^ Lancet,  July  1869,  p.  230. 


342 


HOSPITALISM  : 


The  seventeen  hospitals  with  100  beds  or  less,  contained  in 
Mr.  Holmes’s  list,  reported  to  him  209  limb-amputations,  with  36 
deaths. 

In  the  course  of  their  inquiry,  Mr.  Holmes  and  Dr.  Bristowe, 
singly  or  together,  “ visited  (says  Mr.  Simon)  in  succession  almost 
every  considerable  hospital  in  England  and  Scotland,  and  all  the 
more  important  hospitals  of  Ireland”  (Sixth  Report,  p.  38).  Unfor- 
tunately, however,  they  seem  to  have  looked  upon  “ cottage  hospi- 
tals ” as  undeserving  of  being  included  within  their  official  Reports, 
though  they  visited  some  of  them  (see  p.  643).  They  refer  to  them, 
however,  in  rather  deprecatory  terms,  as  bearing  upon  the  present 
question  of  the  aggregation  and  isolation  of  patients  in  relation  to 
the  salubrity  of  hospitals.  “ Very  small  hospitals,”  they  pointedly 
observe  (p.  510),  “ are  really  as  healthy  as  large  ones.  . . . But  it 
is,”  they  add,  “ a farce  to  compare  such  places  (cottage  hospitals)  to 
large  roomy  hospitals,  considered  abstractedly  with  reference  to 
their  relative  fitness  for  the  treatment  of  acute  cases.”  Yet  limb- 
amputations  are  (see  Table  L)  nearly  three  times  as  fatal  in  our 
large,  roomy,  and  metropolitan  hospitals,  as  they  are  in  our  small 
cottage  hospitals ! 

As  to  the  diversities  displayed  in  the  death-rates  in  Table  XII. 
of  limb-amputations  in  different  classes  of  hospital,  and  under  other 
conditions,  I believe  them  to  be  regulated  on  a large  scale  by  the 
degree  of  aggregation  or  isolation  of  the  sick ; for,  at  least,  we  have 
reason  for  laying  down  the  following,  as  another  proposition,  viz. — 

Proposition  II. — The  preceding  differences  in  the  death-rates  of 
different  classes  of  Hosioitals  are  “ not  to  he  explained  hy  differences 
either  in  the  constitidion  of  those  operated  upon,  or  in  the  nature 
of  the  injuries  or  diseases  for  ichicli  they  icere  admitted.” 

According  to  one  of  the  many  wise  observations  on  the  question 
of  hospitalism  made  by  Miss  Nightingale,  and  quoted  authoritatively 
and  approvingly  by  Sir  Ranald  Martin  in  Mr.  Holmes’s  System  of 
SiLrgery,  “many  well-intentioned  persons  at  the  present  day”  incor- 
rectly account  “ for  the  high  rate  of  mortality  in  civil  hospitals — 
that  only  the  worst  cases  were  sent  there,  and  sent  only  to  die.” 
(See  Mr.  Holmes’s  Surgery,  vol.  iv.  p.  1028.)  Mr.  Holmes  himself, 
indeed,  has  used  this  same  argument,  in  a greater  or  less  degree,  to 
account  for  the  high  death-rate  after  amputations  in  the  London 
hospitals,  as  compared  with  country  hospitals,  and  above  all  with 


PROPOSITIONS  ON. 


343 


country  private  practice.  But,  at  the  same  time,  he  practically 
gainsays  it  altogether  and  rather  effectually,  in  one  part  of  his  own 
official  Report ; and  thus  he  saves  me  from  the  task  of  answering 
his  reasoning  on  this  point  by  answering  it  himself.  For  the  facts 
stand  as  follows  : — 

Under  the  sanction  of  the  Lords  of  the  Privy  Council,  Mr. 
Holmes  and  Dr.  Bristowe,  besides  visiting  the  leading  British  and 
Irish  hospitals,  were  authorised  to  make  also  an  inspection  “ of  the 
chief  Parisian  hospitals  and  of  their  records”  (p.  38).  In  con- 
nection with  this  latter  portion  of  their  work  they  have  given  (at  p. 
563)  a lengthened  table  of  the  amputations  in  the  Paris  hospitals 
during  1861.  According  to  this  table,  there  were  performed  in 
the  Paris  hospitals  during  that  year,  102  amputations  of  the  thigh, 
leg,  arm,  and  forearm;  and  67  of  the  102  patients  died  ; or  nearly 
1 in  1|  (or  1 in  1*5).  In  the  elaborate  official  quarto  Report  of 
the  Parisian  Hospitals  for  1861,  published  by  M.  Husson,  the  num- 
ber of  limb-amputations  for  this  same  year  (1861)  in  all  the  Parisian 
hospitals  is  given  as  81  ; and  he  shows  in  his  tables  that  64  out  of 
these  81  died  ; or  1 in  P2.  The  mortality,  then,  from  limb-ampu- 
tations in  the  hospitals  of  Paris  is  greatly  higher  than  in  the 
hospitals  of  London.  For — 

In  the  Parisian  hospitals  above  1 in  1 J die  ; 

In  the  London  hospitals  about  1 in  2^  die.^ 

Mr.  Holmes  and  Dr.  Bristowe  comment  upon  this  great  relative 
surplus  in  the  mortality  of  the  limb-amputations  in  the  hospitals  of 
Paris  as  compared  with  the  hospitals  of  London,  and  strongly  ob- 
serve : “ The  death-rates  (in  Paris)  are  evidently  enormous,  and  surely 
not  to  be  explained  by  differences  either  in  the  constitution  of  those 
operated  upon,  or  in  the  nature  of  the  injuries  or  diseases  for  which 
they  were  admitted.”  We  quite  agree  with  them  in  these  obser- 
vations ; but  if  the  observations  hold  true  of  the  Parisian  hospitals 
as  compared  with  those  of  London — do  they  not  hold  with  equal  truth 
of  our  large  and  small  British  hospitals,  as  compared  with  each  other? 

In  Tables  XII.  and  XIH.  we  have  seen  that  the  hospitals  in  our  own 
country  vary,  as  a whole,  in  their  salubrity  as  far  as  limb-amputations 
are  concerned — in  relation  to  their  size,  and  the  degree  of  aggrega- 
tion or  isolation  of  the  sick.  We  know  of  no  other  general  cause 
that  can  explain  this  general  result,  and  when  we  compare  the  mor- 

^ The  mortality  is,  to  state  it  in  other  words,  four  or  five  times  greater  in 
limb-amputations  in  the  Parisian  hospitals  than  it  is  in  the  smaller  hospitals  of 
England  and  Scotland. 

78 


344 


HOSPITALISM  : 


tality  from  limb-amputations  in  the  large  and  metropolitan  hospitals 
of  London,  Edinburgh,  and  Glasgow,  of  1 in  every  2 J operated 
upon,  with  the  amputation  death-rate  in  the  smaller  or  provincial 
hospitals  of  Bristol,  Norwich,  Leeds,  Aberdeen,  etc.,  of  1 in  every  4 
operated  upon,  or  the  diminishing  death-rate  in  the  still  smaller 
hospitals  of  Canterbury,  Salisbury,  Truro,  Paisley,  etc.,  of  less  than 
1 in  every  5 oi  6 operated  upon,  we  confess,  in  the  words  of  Mr. 
Holmes  and  Dr.  Bristowe,  that  the  death-rates  in  our  large  British 
hospitals,  as  compared  with  the  death-rates  in  our  smaller  British 
hospitals,  “ are  evidently  enormous,  and  surely  not  to  be  explained 
by  differences  either  in  the  constitution  of  those  operated  upon, 
or  in  tlie  nature  of  the  injuries  or  diseases  for  which  they  are 
admitted.” 

An  amputation,  for  example,  of  the  thigh,  or  of  the  forearm,  for 
injury  or  for  disease,  is  assuredly  the  same  operation,  and  called 
for  by  the  same  circumstances,  whether  it  be  performed  within  the 
walls  of  a metropolitan  or  of  a cottage  hospital ; but  the  differences 
in  the  results  of  such  operations  upon  a large  scale  in  these  diverse 
localities  are,  in  the  language  of  Mr.  Holmes  and  Dr.  Bristowe, 
“ truly  enormous.”  And  if  the  death-rate  in  such  limb-amputations 
in  our  smaller  hospitals,  and  still  more  in  isolated  houses  and 
dwellings  in  the  country  (see  Table  XII.)  is  “the  normal  rate”  of 
mortality  of  limb-amputations,  then  is  not  the  excess  over  that 
normal  rate  observed  in  our  large  hospitals  a painful  and  prevent- 
able waste  of  human  life,  capable  of  being  averted  by  new  hospital 
arrangements  1 One  chief  aim,  let  us  not  forget,  of  all  surgical  as 
well  as  all  medical  science,  is  the  prevention  of  all  preventable 
deaths. 

Proposition  III. — Limb-amputations  are  more  than  three  times  as 

fatal  in  our  large  and  metropolitan  hospitals  than  the  same 

operations  are  in  private  country  and  provincial  practice. 

This  contrast,  however,  in  regard  to  the  relative  perils  of  the 
four  major  amputations  of  the  limbs,  requires  to  be  stated  more  ex- 
plicitly than  I have  already  stated  it,^  and  in  various  correlative 
propositions,  as  it  bears  greatly  upon  the  present  discussion.  Let 
me  therefore  premise  that  above  twenty  years  ago  I published  the 
opinion  that  a great  saving  of  human  life  would  be  effected  in  our 
hospitals  (1)  medical,  (2)  obstetrical,  and  (3)  surgical — if  they  were 


’ See  Table  XII.  1 and  5. 


PROPOSITIONS  ON. 


345 


all  changed  from  palaces  to  villages,  and  from  large  wards  into 
isolated  rooms. ^ At  that  time  no  statistical  proofs  had,  as  far  as 
I was  aware,  been  collected  on  the  subject. 

I elsewhere*  pointed  out  two  years  ago  that  any  direct  evidence 
on  the  question  of  .(1)  medical  hospitals  was  still  wanting.  But  per- 
haps it  will  yet  be  found,  in  ascertaining  the  relative  mortality  of 
typhus  or  typhoid  fever,  or  some  other  medical  disease  as  treated  in 
hospitals  or  at  the  patients’  own  homes  in  the  city  or  in  the  country. 

Latterly,  large  statistics  have  been  collected  on  the  same  question 
in  relation  to  (2)  obstetrical  hospitals.  Dr.  Lefort  of  Paris,  for 
example,  in  a remarkable  work  on  Maternities,  has  collated  the 
results  of  nearly  a million  women  delivered  in  the  lying-in  hospitals 
of  Europe,  and  nearly  an  equal  number  of  pauper  patients  confined 
in  their  own  homes,  with  the  following  results  : — 

Table  XIV. — Kelative  Mortality  attendant  on  Parturition  among 
POOR  Patients  delivered  in  Lying-in  Hospitals,  and  delivered 

AT  THEIR  OWN  HOMES. 

Of  888,302  delivered  in  hospitals  . 30,394  died,  or  1 in  29. 

Of  934,781  delivered  at  home  . . 4,405  died,  or  1 in  212. 

These  two  sets  of  patients  belong,  according  to  Dr.  Lefort,  to 
the  same  class  of  society ; and,  without  entering  into  various 
questionable  points  connected  with  the  table,  we  cito  it  here  as 
sufficient  to  show — what  is  now  generally  acknowledged — namely, 
the  greater  danger  to  life  which  women  undergo  who  are  confined 
in  lying-in  hospitals,  as  these  and  other  hospitals  are  at  present  con- 
structed and  conducted. 

Two  or  three  years  ago*  I suggested  as  an  important  correlative 
question  in  regard  to  surgical  patients  in  (3)  surgical  hospitals,  as 
compared  with  surgical  patients  treated  at  home,  that  the  same  law 
holds  good  in  respect  to  them  as  in  respect  to  obstetrical  patients. 
In  other  words,  are  not  operations  relatively  more  dangerous  and 
fatal  among  the  poor  patients  lodged  in  the  wards  of  our  large 
hospitals  than  among  the  poor  patients  who  are  submitted  to  the 
knife  of  the  surgeon  in  their  own  isolated  dwellings  ? 

The  criterion  most  frequently  adopted  for  testing  the  general 
success  of  surgical  operations  as  a whole — under  different  conditions 
and  in  different  hospitals— is  the  relative  mortality  of  the  four 
^ Edinburgh  Journal  of  Medical  Science,  for  November  1848,  p.  328. 

^ Transactions  of  the  Social  Science  Association  for  1867,  p.  115. 

® Transactions  of  Belfast  Meeting  of  Social  Science  Association. 


346 


HOSPITALISM  : 


major  amputations  of  the  limbs.  For  limb-amputations  do  not 
require  for  their  execution  any  such  high  exercise  of  surgical  skill 
as  herniotomy,  lithotomy,  excision  of  joints,  and  other  operations 
do  ; and  besides  limb-amputations  are  performed  in  such  numbers, 
both  in  hospital  and  private  country  practice,  as  to  afford  an  ade- 
quate basis  of  comparison.^ 

In  consequence,  I have  collated  and  published  the  results  of 
2098  limb-amputations  performed  in  country  private  practice,  and 
2089  limb-amputations  performed  in  our  large  and  metropolitan 
hospitals.  The  difference  between  these  two  classes  of  amputations 
is  shown  in  the  following  table  : — 

Table  XV. — Kelative  Mortality  between  two  series  op  Limb- 
Amputations  IN  Rural  Practice  and  in  the  Practice  op  our 
Large  and  Metropolitan  Hospitals. 

Total  country  cases,  2098  ; deaths,  226,  or  1 in  9 died. 

Total  hospital  cases,  2089  ; deaths,  855,  or  Pin  2|-  died. 

But  the  contrast  between  the  success  of  limb-amputations  in 
rural  private  practice  and  in  city  hospital  practice,  becomes  even 
more  marked  when  we  use  for  comparison  the  results  obtained  by 
experienced  country  surgeons  with  the  results  obtained  by  city 
hospital  surgeons,  who  are  relatively  much  more  experienced  in 
such  operations  than  is  the  general  run  of  country  medical  men. 
In  other  words,  it  may  be  laid  down  as  another 

Proposition  IY. — In  country  j)ractice  increased  experience  in  amputa- 
tions gives  a still  higher  rcdio  of  success  to  the  results  of  the 
operations. 

The  2098  limb-amputations  which  have  been  reported  to  me 
from  the  country  were  performed  by  374  practitioners. 

Of  these  374  medical  gentlemen,  255  had  amputated  less  than 
six  times;  72  of  them  only  once;  82  twice,  etc.;  and  altogether 
they  had  removed  629  limbs.  Of  the  374  practitioners,  72  had 
amputated  from  six  to  twelve  times,  and  removed  648  limbs  in  all. 
While  of  the  374,  the  remainder  (37)  had  amputated  twelve  times 
or  oftener,  and  had  cut  off  altogether  821  limbs. 

The  bearing  of  the  effects  of  experience  upon  the  results  is 
shown  in  the  following  table. 

^ According  to  Professor  I..awrie,  amputation  “ in  hospitals  exceeds  manifold 
all  tlie  other  capital  operations  combined.” — Mecliccd  Gazette  for  December  1810, 
p.  394. 


PROPOSITIONS  ON. 


347 


Table  XVI. — The  Death-rate  of  Limb- Amputations  in  Country 
Practice  as  so  far  varied  by  the  experience  op  the  Operators 

Those  who  had  under  G amputations  . . lost  1 in  7. 

Those  who  had  from  6 to  1 2 ditto  . . . lost  1 in  9. 

Those  who  had  1 2 or  more  ditto  ....  lost  1 in  1 2. 

The  result  is  thus  so  far  influenced  that — as  shown  in  the  last 

line  of  the  table — the  experienced  country  surgeon  operating  upon 
his  patients  generally  in  cottages  and  villages,  is,  as  compared  with 
the  experienced  city  surgeon  operating  upon  his  patients  in  rich  and 
magnificent  hospitals — five  times  more  successful. 

In  supplement  to  Proposition  III.  we  may  add  as 

Proposition  V. — Limh-Ampuiations  in  country  practice  are  far 
more  successful  as  compared  with  the  practice  of  large  hospitals^ 
not  only  when  taken  as  a wlCole^  hut  when  the  amputations  are 
taken  singly  and  individually. 

Under  the  third  proposition  we  have  compared  together  the 
country  and  hospital  mortality  attendant  on  the  four  major  am- 
putations of  the  limbs  when  considered  together  or  as  a whole. 
The  four  single  amputations,  when  taken  individually,  present — as 
might  be  expected — analogous  differences.  Out  of  669  amputations 
of  the  thigh,  collated  from  country  practice,  123  died,  or  about  18 
per  cent ; out  of  935  amputations  of  the  thigh  in  our  large  hospitals 
435  died,  or  about  46  per  cent.  Out  of  618  cases  of  amputations 
of  the  leg  in  country  practice  82  died,  or  13  per  cent ; while  out  of 
613  leg-amputations  in  hospitals  270  died,  or  44  per  cent.  Out  of 
344  cases  of  amputations  of  the  arm  in  country  practice  14  died, 
or  4 per  cent ; while  out  of  297  similar  cases  in  our  large  hospitals 
110  died,  or  37  per  cent.  And  out  of  378  cases  of  amputations  of 
the  forearm  in  country  practice  2 died,  or  about  J per  cent ; while 
out  of  244  cases  of  the  same  operation  in  hospital  practice  40  died, 
or  about  16  per  cent.  These  data  may  appear  more  clear  if 
tabulated  thus  : — 

Table  XVII. — Differences  in  the  Percentages  of  Death  after 
Individual  Amputations,  AS  observed  in  2089  Limb-Amputations 
IN  Hospital  Practice,  and  2098  in  Country  Practice. 

Site  of  Amputation.  In  large  Hospitals.  In  Country. 

Thigh  . 46  in  100  . . 18  in  100 

Leg  . . , 44  „ . , 13  „ 


348 


HOSPITALISM  : 


Site  of  Amputation. 
Arm 

Forearm  . 


In  large  Hospitals. 

37  in  100 
16  „ 


In  Country. 
4 in  100 


The  preceding  data  point  to  a still  more  important  and  un- 
expected result,  which  may  be  stated  in  another  proposition  as 
follows : — 


PnoposiTiON  VI. — The  contrast  hetiveen  the  mortality  of  am^jutations 
in  country  practice^  as  compared  with  hospital  practice^  is  propor- 
tionally more  marked  and  pronounced  in  the  slighter  than  in  the 
greater  amputations  of  the  limbs. 

The  four  amputations  of  the  limbs  vary  in  their  mortality,  as  is 
well  known,  in  the  following  order — namely,  1,  and  most  perilous, 
the  thigh ; 2,  the  leg ; 3,  the  arm ; and  4,  the  forearm.  The 
fatality,  however,  attendant  in  country  practice,  as  compared  with 
city  hospital  practice,  upon  amputation  of  the  thigh,  is  much  less 
marked  than  is  the  difference  attendant  upon  amputation  of  the 
forearm.  The  following  table  points  out  this  and  other  circumstances 
pertaining  to  the  present  proposition  : — 


Table  XVIII. — Contrast  of  the  Death-Rates  in  Country  and  City 
Hospital  Practice  among  the  four  Major  Amputations  of  the 
Limbs. 


Individual  Amputations. 

Amputation  of  thigh 
Amputation  of  leg 
Amputation  of  arm 
Amputation  of  forearm 


Death-rate 
in  Hospitals. 

1 in  2 die 
1 in  2^  die 
1 in  2J  die 
1 in  6 die 


Death-rate 
in  Country. 

1 in  5^  die. 
1 in  7 J die. 
1 in  22  die. 
1 in  189  die. 


Thus,  whilst  in  amputations  of  the  lower  extremity  the  success 
of  country  operations  over  hospital  operations  is  somewhat  about 
three  times  greater,  that  of  amputations  of  the  arm  in  the  country  is 
about  eight  or  nine  times  greater  than  in  the  practice  of  our  large 
and  metropolitan  hospitals.  And  the  relative  differences  in  ampu- 
tations of  the  forearm  under  the  two  conditions  are  so  marked  as  to 
deserve  some  separate  consideration — the  more  so  as  Mr.  Holmes 
adverts  to  them  specially. 


Proposition  VII. — Amputations  of  the  forearm  are  about  twenty  or 
thirty  times  more  successf  ul  in  country  practice  than  in  the  practice  of 
our  large  and  metropolitan  hospitals. 

In  his  account  of  the  amputations  at  St.  George’s  Hospital,  Mr. 


PROPOSITIONS  ON. 


349 


Holmes  discards  the  statistical  worth  of  a tabulation  of  amputations 
of  the  forearm  in  the  following  terms: — “Nor  have  I thought  it 
necessary  to  tabulate  the  amputations  of  the  forearm,  inasmuch  as 
death  after  this  operation  is  so  rare. that  no  useful  end  would  be 
gained  by  such  tabulations.”' 

I believe  that  Mr.  Holmes  will  get  few  or  no  statisticians  to  join 
him  in  this  peculiar  opinion,  for  in  reality  the  statistics  of  forearm 
amputation  are — in  such  an  inquiry,  for  example,  as  the  present — 
full  of  paramount  interest  and  importance. 

In  my  collection  of  2098  country  and  2089  hospital  amputations, 
the  proportions  of  forearm  amputations  and  their  results  stand  as 
follows : — 

Table  XIX. — Numbers  and  Kelative  Fatality  op  Forearm- Amputa- 
tions IN  Country  and  in  Hospital  Practice. 

In  country  practice,  out  of  378  cases,  2 died,  or  1 in  189. 

In  hospital  practice,  out  of  244  cases,  40  died,  or  1 in  6. 

With  reference  to  these  40  forearm-amputations  in  the  last  line, 
Mr.  Holmes  demands  how  is  it  possible  to  know  that  this  excess  of 
40  deaths  in  hospital  -practice  “ is  caused  by  hospital  arrangements, 
without  knowing  the  causes  of  death  ? ” and  he  cites  a conversation 
with  me  on  the  matter,  in  which  it  seems  I mentioned  the  causes  of 
death  were  not  necessary  elements  in  an  inquiry  into  the  simple 
rates  of  death  after  forearm  or  other  amputations  under  different 
conditions  of  practice.  Mr.  Holmes  has  here,  it  appears  to  me, 
confounded  two  things  that  are  quite  different,  or  rather  two 
different  and  distinct  kinds  of  inquiry.  In  Table  XIY.  we  have 
seen  Dr.  Lefort  laying  it  down  as  the  result  of  his  extensive  statis- 
tical investigations  into  the  mortality  of  parturition  in  hospital 
practice  and  in  home  practice,  that  whilst  1 in  29  women  die  who 
are  delivered  in  hospitals,  only  1 in  212  die  who  are  delivered  in 
their  own  isolated  homes.  That  important  statistical  induction  as 
to  the  high  rate  of  death  of  women  in  lying-in  hospitals,  is  a deduc- 
tion totally  independent  of  what  is  the  cause  of  death  in  these  “ 1 
in  29  women”  who  thus  die,  according  to  Dr.  Lefort,  in  our 
maternity  hospitals  after  parturition.  The  causes  of  the  excessive 
mortality  of  parturient  women  in  hospital  practice  form  a totally 
different  question  from  the  mere  statistical  fact  of  that  great  excess 
itself.  So,  in  the  same  way,  the  startling  fact  that  amputation  of 

^ See  St.  George's  Hosintal  Re'ports,  vol.  i. 


350 


HOSPITALISM  : 


the  forearm  is  twenty  or  thirty  times  more  dangerous  and  lethal  in 
the  practice  of  our  large  and  metropolitan  hospitals  than  in  private 
country  practice,  is  a hict  totally  independent  of  wdiat  are  the 
causes  of  death  which  lead  to  this  peril  and  fatality  in  the  wards  of 
our  palatial  hospitals  from  comparatively  so  simple  an  operation, 
and  one,  seldom  or  never  almost  either  preceded  or  followed  by  any 
great  shock  to  the  system,  such  as  we  see  in  amputations  of  the 
thigh  and  leg.  The  rates  of  death  and  the  causes  of  death  after 
amputations  are,  in  short,  two  different  questions. 

But  the  causes  of  such  mortality  form  a subject  of  investigation 
which,  while  it  is  distinct  from,  is  at  the  same  time  second  only  in 
importance  to,  the  ascertainment  of  the  mortality  itself.  Mr. 
Holmes  seems  inclined  to  argue  that  the  causes  of  the  excessive 
mortality  of  the  forearm-amputations  in  hospitals  are  not  traceable 
to  “ hospital  unhealthiness.”  But  we  may  lay  down  the  contrary  as 
a simple  and  just  inference — thus  : 

Proposition  VIII. — The  deaths  after  amputation  of  the  forearm  in 
hospitals  result,  in  the  main,  from  those  jjathological  causes  which  are 
usually  ascribed  to  morbific  hospital  influences. 

The  general  and  acknowledged  cause  of  death  after  operations 
in  hospitals  is  some  of  the  forms  of  surgical  fever — as  pyiemia, 
erysipelas,  phagedena,  etc. 

Mr.  Holmes  himself  has  ably  described  these  complications  as 
the  general  pathological  causes  of  death  after  surgical  operations  in 
surgical  hospitals.  “All  surgeons  ” (observe  he  and  Dr.  Bristowe  in 
their  Report,  p.  544)  “attached  to  large  metropolitan  hospitals  are 
aware  that  their  operations  are  apt  occasionally  to  be  carried  off  by 
the  supervention  of  erysipelas,  pyaemia,  or  hospital  gangrene,  or  some 
allied  unhealthy  form  of  inflammation.  . . Their  frequent  recur- 

rence, or  their  prevalence  in  an  endemic  form,  is  an  indication  of 
unhealthiness  in  the  hospital.  . . Erysipelas  sometimes,  but  not 

frequently,  proves  fatal  to  surgical  operations.  Pyaemia  is  certainly 
the  most  commonly  fatal  of  secondary  surgical  affections”  (p.  54G). 

Mr.  Holmes  states'  that  during  the  last  fourteen  years  4 patients 
have  died  in  St.  George’s  Hospital  out  of  41  upon  whom  amputation 
of  the  forearm  has  been  performed.  In  the  St.  George's  Hospital 
Reports,  vol.  i.,  he  gives  an  account  of  the  causes  of  death  in  these 
cases  as  follows  : — “ One  died  of  pyaemia  in  fifty-two  days.”  In  a 


^ See  Lancet,  August  18C9,  p.  2978. 


TROPOSITIONS  ON. 


351 


second  fatal  case  “ the  wrist-joint  had  been  disorganised  by  an 
attack  of  pyaemia,  from  which  the  patient  had  recovered.  It 
became  necessary  to  remove  the  hand,  but  the  pyaemia  recurred, 
and  he  died  on  the  forty-fifth  day  after  ami)utation.”  In  a third 
case  the  patient  died  of  secondary  hemorrhage  on  the  thirty-third 
day,  the  vessels  being  diseased.”  “ No  hospital  arrangements  (pleads 
Mr.  Holmes)  will  prevent  brittle  arteries  from  bleeding  sometimes 
but  in  isolated  country  practice,  the  vessels,  and  indeed  the  wound 
itself,  would  in  all  likelihood  have  been  closed,  and  all  chances  of 
hemorrhage  averted,  long  before  the  thirty-third  day  of  the  cure. 
In  the  fourth  fatal  case,  which,  says  Mr.  Holmes,  “ was  a primary 
amputation,”  the  patient  (aged  eighty-one)  was  attacked  with  senile 
gangrene  in  the  legs,  and  “ she  died  on  the  thirty-eighth  day.”  In 
the  same  paper  Mr.  Holmes  states  that  in  the  Amputation  Book  of 
St.  George’s  Hospital,  kept  for  the  last  sixteen  years,  “ tliere  have 
been  4 deaths  after  amputation  of  the  forearm  among  41  cases,” 
giving  a mortality  of  1 in  10.  But  Mr.  Holmes  has  described  what 
is  apparently  a fifth  case.  To  use  his  own  words,  “ the  man  was 
very  old — nominally  sixty-seven,  really  perhaps  many  years  older, — 
and  obviously  near  the  end  of  his  life  when  admitted.  The  opera- 
tion was  done  to  free  him  from  the  exhaustion  caused  by  abscess  of 
the  wrist ; but  he  gradually  sank,  as  he  had  been  sinking  before 
admission,”  etc.^ 

Without  stopping  to  debate  whether  these  cases  chiefly  sank,  as 
I think,  from  causes  of  death  pertaining  more  or  less  to  hospitalism 
and  its  effects,  let  me  add  that  the  experience  of  other  hospitals 
leaves  no  doubt  on  this  subject. 

Mr.  M‘Dougall  and  Dr.  Aitken  have,  for  example,  ascertained 
for  me  the  registered  causes  of  death  in  the  fatal  cases  of  amputa- 
tion of  the  forearm  that  have  taken  place  in  the  Edinburgh 
Infirmary  during  the  last  four  years  ; for  it  seemed  quite  unne- 
cessary to  push  the  inquiry  farther.  From  1864  to  1868  there 
occurred  in  the  infirmary  23  primary  amputations  of  the  forearm 
with  5 deaths,  and  9 secondary  or  pathological  amputations  with  4 
deaths.  The  cause  of  death  in  1 of  the  primaries  is  noted  as 
unknown  or  unascertained ; in  2 it  resulted  from  tetanus  ; and  in 
^ If  this  is,  as  it  appears,  a fifth  case  of  death,  then  the  mortality  in  forearm- 
amputations  at  St.  George’s  in  the  sixteen  years  referred  to  would  he  5 in  40,  or  1 
in  8.  It  appears  not  to  be  the. fourth  fatal  ease  referred  to  in  Mr.  Holmes’s  paper 
in  the  St.  George's  lleports,  because  the  patient  was  a male,  the  other  a female  ; 
the  operation  was  for  disease,  and  not  “primary  ; ” and  the  patient  was  sixty- 
Reven  years  of  age  or  more,  the  other  eighty-one  years. 


352 


HOSPITALISM  : 


the  remaining  2 from  pysemia.  Of  the  4 deaths  after  amputation 
for  disease,  1 was  entered  as  from  shock,  and  the  3 others  all  died 
from  pyaemia. 

Of  8 deaths  after  amputation  of  the  forearm  at  Guy’s  Hospital, 
Dr.  Steele  informs  me  that  3 were  from  pyaemia ; a fourth  was 
from  pleurisy  (perhaps  merely  one  form  of  pyaemia) ; a fifth  from 
tubercular  phthisis ; and  a sixth  from  phagedenic  sloughing  and 
pleurisy  (possibly  pyaemic).  A seventh  death  was  from  tetanus ; 
and  the  eighth  from  cancer  of  internal  organs. 

Perhaps  another  piece  of  evidence  in  regard  to  the  fatality  of 
forearm-amputations  in  hospitals  may  be  added.  Mr.  Holmes  and 
Dr.  Bristowe  had,  as  already  stated,  an  opportunity  given  them  by 
the  Lords  of  the  Council  of  visiting  the  hospitals  of  Paris,  and  of 
inspecting  them  and  “ their  records.”  They  have  published,  as  we 
have  already  seen,  from  these  official  records  the  amputation 
statistics  of  the  Parisian  hospitals  for  1861.  In  the  authorised 
records  of  that  year,  as  published  by  M.  Husson,  there  are  reported 
7 cases  of  amputation  of  the  forearm  in  the  different  Parisian 
hospitals.  Of  these  7 cases  4 died.  Of  the  7 cases,  4 are  noted  as 
having  been  attacked  with  erysipelas  ; 1 of  the  4 had  in  addition 
abscesses,  and  1 is  entered  with  “ purulent  ” infection  or  pyaemia — 
all  of  them  so  many  forms  and  varieties  of  that  surgical  fever  which 
is  so  destructive  in  hospitals. 

In  M.  Husson’s  Deport  of  the  Statistics  of  the  hospitals  of  Paris 
for  the  subsequent  year  (1862)  18  cases  of  amputation  of  the 
forearm  are  recorded,  with  6 deaths.  The  cause  of  death  after  one 
of  these  6 fatal  forearm-amputations  is  not  reported.  Of  the 
remaining  5 cases,  one  died  of  phthisis,  a second  of  erysipelas,  and 
the  remaining  three  of  purulent  infection  or  pyaemia. 

When  speaking  of  the  “ enormous”  death-rates  after  limb- 
amputations  in  the  Parisian  hospitals,  as  compared  with  the  London 
hospitals,  Mr.  Holmes  and  Dr.  Bristowe  remark  that  “ pyaemia  and 
such  diseases  are  in  great  measure  the  causes  of  these  alarming 
results.”  So  are  they  also  the  apparent  causes  of  the  higher  death- 
rates  after  operations  in  our  own  large  as  compared  with  our 
smaller  British  hospitals,  and  of  the  “ alarming  results  ” attendant 
upon  amputations  of  the  forearm  in  country  practice  and  amputa- 
tions of  the  forearm  in  hospital  practice.* 

^ The  two  fatal  cases  reported  to  me  after  amputation  of  the  forearm,  out  of 
378  cases  operated  on  in  country  practice,  are  both  returned  as  having  died  of 
“ gangrene.  ” 


PROPOSITIONS  ON. 


353 


After  such  evidence,  no  surgical  pathologist  will,  I am  inclined 
to  believe,  be  disposed  to  deny  that  the  excess  of  mortality  of 
forearm-amputations  in  hospital  practice,  as  compared  with  country 
practice,  is  mainly  and  directly  due  to  deleterious  hospital  influences. 
For,  according  to  Mr.  Holmes’s  own  evidence  in  regard  to  deaths 
after  amputation  in  hospital  practice,  “ the  rate  of  mortality  varies 
with  the  prevalence  of  pysemia ; ” ‘ and  in  the  above  extracts  we 
have  seen  how  greatly  pyaemia,  with  its  congener  types  of  disease, 
was  mixed  up  with  these  fatal  cases  of  forearm-amputation. 

As  additional  evidence  of  the  relative  safety  of  limb-amputa- 
tions, and  consequently  of  other  operations,  in  isolated  country 
dwellings,  as  compared  with  hospital  wards,  let  me  add  two 
paradoxical-like  propositions  regarding  the  greater  safety,  in  rural 
practice,  of  double  amputations,  and  of  amputations  upon  the  aged. 

Proposition  IX. — Double  amputations  are  very  fatal  in  hospital 
practice^  but  are  recovered  from  in  private  country  practice  in 
as  great  proportion  as  single  amputations  are  recovered  from  in 
large  and  metropolitan  hospitals. 

I do  not  know  of  any  statistics  to  show  the  mortality  attendant 
on  double  amputations  on  the  same  individual  in  hospital  practice ; 
but  they  are  known  to  be  extremely  fatal,  especially  when  one  of 
the  two  amputations  is  of  the  thigh.  In  the  last  10  double 
amputations  performed  in  the  continuity  of  the  bones  of  the  extre- 
mities in  the  Infirmary  of  Edinburgh,  all  the  10  perished. 

Out  of  23  double  amputations  reported  to  me  and  performed  in 
country  practice  for  complex  injuries,  making  46  limb-amputations 
in  all,  only  7 of  the  patients  died — less  than  1 in  3.'^  In  our 
large  and  metropolitan  hospitals  the  mortality  already  stated 
attendant  upon  single  amputations  is  greater  than  this,  as  already 
shown  in  Tables  XIL,  XY.,  etc. 

Proposition  X. — Limb- amputations,  ivhen  performed  on  persons 
above  seventy  years  of  age,  form  very  fcdal  operations  in  hospitals  ; 
but  in  isolated  rooms  in  country  practice  they  are  not  more  lethal 
than  are  limb-ampidations  in  hospital  practice  ivhen  executed  upon 
persons  of  all  ages. 

In  his  excellent  paper  on  the  statistics  of  the  hospitals  of  Paris, 
published  in  1862,  Mons.  Trelat  remarks,  with  reference  to  the 
^ See  St.  Georges  Hospital  Reports,  vol.  i.  p.  328. 


2 See  Table  II. 


354 


HOSPITALISM  : 


mortality  of  amputations,  that  “ beyond  seventy  years  of  age  it 
(this  mortality)  becomes  so  large  as  95  per  cent — that  is,  1 only 
recovers  out  of  20  operated  on.”  Hence,  M.  Trelat,  remarks  Pr. 
Ranking,  “ reprobates  amputation  in  those  above  seventy  years  of 
age.”  ^ In  a similar  spirit  Mr.  Holmes  observes,  in  regard  to  limb- 
amputations  after  the  age  of  seventy,  “The  larger  amputations 
would  be  hardly  justifiable  except  for  accidents,  though  even  here 
the  prospect  of  recovery  is  so  slight  that  it  becomes  a question 
whether  it  would  not  be  better  to  allow  the  patient  to  .die  unmo- 
lested by  the  operation.”  ^ 

But  while  limb-amputations  are  very  deadly  and  fatal  when 
performed  upon  the  old  in  our  rich  hospital  wards,  the  very  same 
operations  are  not  more  fatal  to  the  old,  in  rural  practice,  than  are 
limb-arnputatioiis  performed  upon  people  of  all  ages  in  our  large 
and  metropolitan  hospitals.  In  the  2098  country  amputations 
reported  to  me,  22  are  incidentally  stated  to  have  been  performed 
on  persons  above  seventy.  Of  these  22  cases,  6 were  amputations 
of  the  thigh,  9 were  amputations  of  the  leg,  5 of  the  arm,  and  2 of 
.the  forearm.  Of  the  22  patients  8 died,  or  1 in  2 ’7  ; whilst  the 
mortality  in  our  large  and  metropolitan  hospitals,  in  limb-amputa- 
tions, upon  persons  of  all  ages,  is  1 in  2 ‘4. 

In  his  paper  in  the  The  Lancet,  Mr.  Holmes  propounds  a 
surgical  syllogism:  — “No  hospital  arrangements  (says  he)  will 
make  an  old  man  into  a young  one.”  I subscribe  to  this  position ; 
but  at  the  same  time  I submit  that  in  the  preceding  facts  we  have 
something  not  unlike  Mr.  Holmes’s  own  suggested  metamorphosis 
effected — as  far  at  least  as  regards  the  power  of  sustaining  the 
dreadful  operation  of  dismembering  a human  being.  It  seems  to 
be  effected,  further,  by  no  sorcery  more  weird  and  mystical  than 
placing  aged  patients,  when  they  are  to  be  operated  upon,  out  of 
the  conditions  of  hospital  aggregation,  which  he  recommends,  and 
into  the  conditions  of  separation  and  isolation  which  I have  ven- 
tured to  recommend.  And  if  such  simple  necromancy  produce  such 
very  strange  and  unexpected  results  upon  very  old  surgical  patients, 
why  should  it  not  produce  equal  and  corresponding  salubrious 
changes  upon  surgical  and  other  patients  of  all  ages  1 

In  previous  propositions  we  have  seen  that,  as  general  laws — 
liable,  of  course,  like  all  other  general  laws  in  medical  science,  to 
various  local  and  other  exceptions — amputations  of  the  limbs  in 

^ See  banking’s  Ilcdf-yearhj  Abstract  of  Medical  Sciences,  vol.  xxxvi.  p.  197. 

^ See  St.  Gcorye's  Hospital  Heports^  vol.  i.  p.  301. 


PEOPOSITIONS  OX. 


355 


hospitals  become  more  and  more  dangerous  and  fatal  in  their  results 
in  proportion  as  the  hospitals  in  which  they  are  performed  are  in- 
creased in  size ; and,  on  the  contrary,  they  become  less  and  less 
perilous  and  lethal  in  proportion  as  the  hospitals  in  which  they  are 
placed  are  decreased  in  size.  In  other  wmrds,  we  have  found  that 
the  congregation  of  patients  upon  a given  spot,  or  within  a given 
establishment,  enhances  the  chances  of  death  to  those  that  are  tliere 
operated  upon  and  treated  ; while,  on  the  other  hand,  the  more  that 
patients  are  separated  and  isolated  they  recover  the  more  surely  from 
the  knife  of  the  surgeon,  and  in  all  probability,  also,  from  other 
accidents  and  diseases.  There  is  safety  in  segregation — danger  in 
aggregation. 

The  comparative  degree  of  safety  and  danger  pertaining  to 
patients  obliged  to  undergo  amputation  of  the  limbs,  when  placed 
under  different  external  conditions  and  amounts  of  aggregation,  may 
be  shown  in  percentages  in  such  a table  as  follows.'  In  tliis  table 
I have  placed  on  the  first  line  the  mortality  from  limb-amputations 
in  the  larger  hospitals  of  Paris,*  as  officially  given  by  M.  Ilusson, 
for  the  ^ears  1861-63,  the  latest  statistics  hitherto  published  by  him. 
The  other  calculations  are  death  percentages  in  round''  numbers, 
calculated  from  upwards  of  7000  limb-amputations^  in  Great  Britain 
which  I have  collected. 

^ See  previously  its  analogue  in  proportional  numbers  in  Table  XII. 

2 1 believe  that  St.  Bartholomew’s,  London,  is  the  only  British  civil  hospital 
which  contains  upwards  of  600  beds.  Mr.  Holmes  and  Dr.  Bristowe  speak  of 
their  number  as  650.  Several  of  the  Parisian  hospitals — as  the  Hotel  Dieu,  Pitie, 
Lariboisim-e,  Saint  Louis,  and  Enfans  Malades — contain  from  600  to  800  beds. 
The  Parisian  hospitals,  and  even  those  that  are  comparatively  small,  seem  to 
have  generally  their  wards  more  crowded  with  beds  and  patients  than  the 
hospitals  of  England  and  Scotland. 

^ The  actual  or  true  decimal  figures  in  this  table  (Table  XX.)  are,  reckoning 
from  below  upwards,  lO’S,  13-8,  177,  22-6,  29  6,  and  41-1. 

^ I have  already  given  in  detail  (See  Chaps.  1.  and  II.)  the  statistics  of  the 
amputations  in  our  large  and  metropolitan  British  hospitals,  and  in  country 
private  practice  ; and  betimes  I will  give,  in  the  same  manner,  the  full  details  of 
upwards  of  3000  limb-amputations  reported  to  me  from  the  provincial  hospitals 
of  Great  Britain,  and  which  I have  now  summarised.  The  round  percentages 
ill  the  table  give  a just  and  faithful  view  of  the  general  results.  If  any  mis- 
takes in  the  numbers  or  calculations  can  be  pointed  out,  I shall  of  course  be 
happy  to  rectify  them  ; but  surely,  in  a professional  discussion  such  as  the  present, 
this  may  be  done  without  that  discourtesy  of  words  that  is  resorted  to  in  the 
last  Lancet  by  a London  hospital  surgeon. 


356 


HOSPITALISM  : 


Table  XX. — Percentages  op  Death  after  Limb-Amputations  under 
Different  Conditions  and  Degrees  op  Aggregation  and 
Isolation. 


Condition  and  size  of  Hospital. 


Percentage  of 
Death-Kate. 


In  the  large 

Parisian  hospitals 

. 62 

in  100  die. 

In  British  hospitals 

with  300  to  600  beds 

. 41 

In  „ 

with  300  to  201  beds 

. 30 

n 

In  „ 

5? 

with  200  to  101  beds 

. 23 

In  „ 

with  100  to  26  beds 

. 18 

In  „ 

with  25  beds  or  less 

. 14 

In  isolated  rooms  in  country  practice 

. 11 

Mr.  Holmes,  as  we  have  already  seen,  properly,  I believe,  holds 
that  the  difference  between  the  death-rates  after  amputation  in  the 
large  hospitals  of  Paris  and  of  Great  Britain  is  enormous  and,  to 
use  his  own  words,  “ surely  not  to  be  explained  by  differences  either 
in  the  constitutions  of  those  operated  upon,  or  in  the  nature  of  the 
injuries  and  diseases  for  which  they  are  admitted.”  The  preceding 
table  shows  the  difference  between  the  death-rate  in  the  Parisian  and 
in  our  own  large  British  hospitals  to  be  20  per  cent.  In  other 
words,  out  of  every  1000  subjected  to  limb-amputations  in  the 
Parisian  hospitals,  200  more  die  than  die  out  of  the  same  number  of 
amputation  cases  in  the  large  hospitals  of  London,  Edinburgh,  and 
Glasgow.  But  our  table  further  shows  that  out  of  every  1000  cases 
of  limb-amputation  performed  in  our  largest  British  hospitals,  nearly 
200  more  die  than  there  die  of  the  same  operation  in  smaller  British 
hospitals  containing  from  100  to  200  beds,  and  400  more  than  are 
lost  when  the  operation  is  done  upon  patients  living  in  isolated 
rooms  in  country  or  provincial  practice. 

Previously  I have  ventured  to  lay  it  down  as  a proposition  (see 
Proposition  11.)  that  to  account  for  the  appalling  loss  of  life  after 
amputation  in  our  larger  as  compared  with  our  smaller  British 
hospitals,  the  relative  severity  of  the  injuries  and  diseases  for  which 
the  amputations  are  performed,  or  the  constitutions  of  the  patients, 
etc.,  afford  no  adequate  explanation.  Further,  I hold  that  in  this 
inquiry  this  may  be  laid  down  as  another  and  equally  valid 


PEOPOSITIONS  ON. 


357 


Proposition  XI. — The  differences  between  the  death-rates  after  limb- 
amputations  in  country  practice  and  in  hospital  practice  are  ( to  re- 
employ Mr.  Holmes's  words ) “ evidently  enormous,  and  surely  not  to 
be  explained  by  differences  either  in  the  constitution  of  those  operated 
on,  or  in  the  nature  of  their  injuries  or  diseases." 

Few  minds,  I believe,  studying  this  matter  de  novo,  will  feel  any 
difficulty  in  assenting  to  the  truth  of  this  proposition,  more  especially 
when  the  gradation  of  the  death-rate  in  amputations  is  seen,  as 
shown  in  Tables  XIL  and  XX.,  to  decrease  so  regularly  and 
methodically  in  proportion  as  the  patients  are  more  and  more 
separated  and  isolated. 

But  Mr.  Holmes — as  yet  at  least — strongly  objects  to  our  present 
proposition,  mainly,  I believe,  from  want  of  adequate  knowledge  on 
his  part  of  the  peculiarities  and  status  of  country  practice  in  many 
districts  of  Great  Britain.  In  this  respect,  matters  both  abroad  and 
in  our  OAvn  country  are  mightily  changed  since  the  beginning  of  the 
last  century,  when  Dionis  tells  us  he  could  not  find  in  the  whole  city 
of  Marseilles  a single  practitioner  who  had  performed  the  excision  of 
a diseased  mamma.  For  there  is  now  scarcely  a village  in  England 
and  Scotland  in  which  we  would  fail  to  meet  a practitioner  capable 
of  performing  that  and  far  more  serious  surgical  operations ; and 
some  country  practitioners,  especially  in  the  mining  and  manufac- 
turing districts,  have  had  as  large  a share  of  primary  amputations  as 
most  hospital  surgeons. 

Mr.  Holmes  objects  to  the  statistics  of  country  amputations  as 
compared  with  hospital  amputations  on  a variety  of  grounds.  Some 
are  so  irrelevant  as  not  to  require  any  reply.  But  on  several  objec- 
tions he  and  others  seem  to  place  much  reliance,  and  therefore  it 
may  be  proper  to  answer  them.  It  matters  little  how  those  objec- 
tions are  arranged.  One  of  the  most  fundamental,  if  it  held  true, 
may  be  stated  as  follows  : — - 

Objection  I.  The  data  are  so  far  too  few,  as  they  give  only  a “ small 
sample  ” of  country  amputations. — The  collection  of  limb-amputations 
which  I have  made  from  British  hospital  and  private  practice  is,  I 
believe,  the  largest  ever  yet  brought  together  for  any  statistical 
inquiry  in  Europe — amounting  as  it  does  now  to  upwards  of  7000 
cases,  above  2000  of  which  were  amputations  performed  by  374 
country  and  provincial  practitioners  in  single  or  isolated  rooms. 
The  collection  is  more  extensive  than  any  of  the  series  of  amputa- 
tions, resections,  lithotomies,  and  herniotomies,  made  under  Govern- 


358 


HOSPITALISM  : 


ment  and  official  influence  by  Mr.  Holmes  and  Dr.  Bristowe.  But 
Mr.  Holmes  objects  to  the  2098  rural  cases  reported  by  me  as  being 
only  a “ small  sample  ” of  the  mass  of  amputations  that  must  be  per- 
formed in  the  country.  Tliis  number  of  amputations,  however,  is  at 
least  somewhat  larger  than  he  and  Dr.  Bristowe  were  content  with 
collecting  from  all  the  hospitals  of  England,  Scotland,  and  Ireland 
that  they  visited,  and  which  smaller  data — viz.  1837 — they  then 
deemed  sufficient  for  their  various  deductions  and  reasonings. 

Another  London  surgeon,  who  has,  like  Mr.  Holmes,  worked 
ably  and  written  much  upon  the  data  of  amputations  in  metropolitan 
and  provincial  hospitals,  took — when  I had  only  1000  cases  collated 
— an  opposite  view  to  him ; and  I willingly  leave  them  to  decide 
who  of  the  two  is  correct,-  and  whether  or  not  both  are  wrong.  This 
second  metropolitan  surgeon,  after  stating  that,  with  all  his  extensive 
statistical  experience,  he  “ should  not  have  known  in  the  least  where 
to  turn  for  the  facts;”  for,  as  he  argues,  “ amputations  in  the  habi- 
tations and  cottages  of  the  poor  are  not  matters  of  every-day  occur- 
rence. . . . From  what  source,”  he  further  asks,  “ can  the 

record  of  1000  amputations  in  private  practice  or  country  practice 
be  obtained  1 — for  we  are  not  sure  that  Sir  James  Simpson  excludes 
small  provincial  hospitals — with  a guarantee,  or  anything  like  a gua- 
rantee, that  all  have  been  given.”  ^ 

I have  excluded,  however,  though  it  is  here  doubted,  from  the 
2000  amputations  in  private  practice  all  hospital  cases  ; and,  in  ask- 
ing country  practitioners  for  their  returns  of  cases,  I specially  re- 
quested, as  stated  in  the  letter  of  application  addressed  to  each,  to 
report  in  his  schedule  ‘‘  all  the  amputations  which  you  may  have 
had  in  your  oiun  practice;”  and  “whether  the  cases  ended  in 
recovery  or  in  death.”  ^ 

To  this  just  and  simple  request  Mr.  Holmes  brings  apparently 
forward  as  another 

Objection  II.  “ The  length  of  time  comprised  in  these  xetnrnsf  in 
some  “ it  extends  hack  more  than  twenty  yearsT — Surely  so  strange  an 
objection  requires  no  reply.  Would  Mr.  Holmes  have  had  me  ask 
each  practitioner  not  for  all  his  amputation  cases,  but  only  those 
that  had  occurred  within  some  specialised  term  of  years  1 Surely 
the  request  would  have  been  perplexing  and  indefensible  in  such  a 
statistical  inquiry.  But  let  Mr.  Holmes’s  metropolitan  colleague 
answer  him  on  this  point ; and  in  this  colleague’s  opinion  every 

1 See  Medical  Times  and  Gazette  for  Jan.  23,  1839,  p.  98. 

2 See  letter  in  the  Edinburgh  Medical  Journal  for  Marcli  1869. 


PROPOSITIONS  ON. 


359 


statistician  will,  I believe,  coincide.  Eeferring  to  the  inodes  of  col- 
lecting country  amputation  returns,  he  observes  : — “ To  pick  up  stray 
cases  from  the  journals  for  such  a purpose  would  be  worse  than 
childish ; nor  would  the  plan  of  taking  a few  years'  report  from  one 
surgeon,  and  a few  from  another,  be  much  better.” 

Objection  III.  Sir  James  Simpson’s  comparison  between  the 
statistics  of  private  practice  in  the  country  and  those  of  hospital  practice 
in  town  is  unfair f because  the  things  thus  compared  are  dissimilar,  and 
the  comparison  is  fallacious. — In  a letter  published  some  months  ago, 
Mr.  Holmes  stated  this  objection  more  explicitly  thus : — “Before 
any  fair  comparison  can  be  made  between  the  results  of  amputations 
in  different  hospitals — how  much  more  between  hospitals  and  private 
practice — it  is  necessary  to  know  something  more  than  how  many 
amputations  have  been  performed  on  account  of  accident,  and  how 
many  on  account  of  disease,  or  the  relative  numbers  which  have  been 
performed  at  the  several  seats  of  amputation.  It  is  necessary  to 
be  acquainted  with  the  condition  of  patients  at  the  time  of  opera- 
tion, and  with  the  actual  cause  of  death  in  those  who  die  after 
operation.”  ^ 

In  this  last  clause  Mr.  Holmes  proposes  to  obtain  acquaintance 
with  the  causes  of  death  after  amputation,  without  even  inquiring 
into  the  rates  of  death — two  investigations  Avhich  I have  shown, 
under  Proposition  VII.,  to  be  quite  different.  In  my  tables  the 
rates  of  death  are  all  strictly  attended  to. 

The  condition  of  persons  at  the  time  of  amputation  will  engage 
us  in  the  sequel,  when  we  shall  find  that  in  more  than  half  of  the 
whole— namely,  in  the  primary  amputations — both  the  country  and 
hospital  patients  were  in  a state  of  ordinary  or  normal  health  imme- 
diately before  the  amputation. 

But  let  me  here  add  a few  remarks  on  the  arrangement  of  the 
amputations  so  as  to  make  the  comparison  between  country  and 
hospital  operations  as  easy  and  certain  as  possible  on  all  points  ; for 
I maintain,  contrary  to  Mr.  Holmes’s  strange  assertion,  that  I have 
not  been  “ scrupulous  to  compare  things  which  are  dissimilar.” 

In  the  7000  and  odd  major  amputations  which  I have  collated, 
.1  have  studied,  as  far  as  possible,  to  arrange  them  and  their  results 
so  that  the  comparison  between  them  should  on  all  points  be  as  easy 
and  free  from  fallacy  as  possible.  For  this  purpose,  after  giving 
both  in  the  lump  and  in  detail  the  amputations  of  each  country 
practitioner  and  each  hospital,  I have  divided  the  whole  amputations 
^ British  Medical  Joimial,  Jan.  23,  1869. 

79 


360 


HOSPITALISM  : 


into  six  classes,  according  as  they  were  performed  in  single  isolated 
rooms  or  in  hospitals  of  various  sizes.  With  the  object  of  attaining 
simple  and  correct  comparison,  I have  subdivided  further  each  of 
these  six  classes  of  cases  into  (1)  limb-amputations  taken  as  a whole, 
(2)  limb-amputations  the  result  of  injury,  and  (3)  limb-amputations 
the  result  of  disease.  By  the  method  adopted  we  can  also  compare 
the  death-rate  of  the  various  individual  amputations — as  the  thigli 
or  the  forearm,  for  instance — in  country  practice,  with  the  death- 
rate  of  amputation  of  the  thigh  or  the  forearm  under  five  or  six 
separate  conditions  of  hospitalism ; and  ascertain  readily,  and  at 
once,  many  different  points  of  relation  and  comparison. 

In  this  way  it  appears  to  me  all  preventable  sources  of  fallacy 
have  been  avoided  to  a degree  that  has  not  hitherto  been  generally 
attempted  in  amputation  statistics.  For  example,  look,  as  a matter 
of  contrast,  at  the  official  list  of  amputations  offered  to  the  Privy 
Council  by  Mr.  Holmes  and  Dr.  Bristowe.  In  their  table,  pages 
555-558,  they  have  congregated  and  lumped  together  their  1800 
and  odd  amputations  without  succeeding  in  dividing  them  into  the 
two  great  and  significant  classes  of  traumatic  and  pathological  am- 
putations, or  amputations  for  injury  and  for  disease — confessedly  a 
very  grievous  omission.  But  other  still  more  unfortunate  errors 
crop  out  in  Mr.  Holmes’s  table.  He  has,  for  instance,  confused  the 
four  major  amputations  of  the  limbs  through  the  continuity  of  the 
bones  with  amputations  through  the  joints ; thus  commixing  am- 
putations of  the  shoulder-joint  with  amputations  of  the  arm,  ampu- 
tations through  the  hip-joint  with  amputations  of  the  thigh,  and 
amputations  of  the  leg  with  amputations  of  the  ankle  and  foot.  To 
show  the  kind  of  mistakes  to  which  such  confusion  may  lead  in  surgical 
statistics,  let  me  point  to  one  instance  only  in  his  table.  Mr.  Holmes 
enters  the  death-rate  in  the  metropolitan  hospitals  from  amputation 
of  the  leg,  under  which  he  includes  amputation  of  the  foot,  as  30  in 
100  ; while  the  actual  rate  of  mortality  of  amputation  of  the  leg  in 
metropolitan  hospitals  is,  as  I have  elsewhere  shown,  as  high  as  44  in 
100.  Mr.  Holmes’s  method  thus  involves  an  error  of  not  less  than 
14  per  cent  in  this  one  amputation  alone,  and  so  far  seriously 
detracts  from  the  value  of  this  and  other  portions  of  his  amputation 
statistics. 

Objection  IV. — The  comparison  beticeen  hospital  and  country  am- 
putations is  “ unfair”  for  the  success  of  the  country  amputations  is  repre- 
sented as  too  high. — Mr.  Holmes  evidently  lays  his  chief  weight  on 
this  objection  ; let  us  therefore  consider  it  more  at  length. 


PROPOSITIONS  ON. 


361 


Now  the  list  of  country  limb-amputations  which  I have  collated 
and  published  amounts  to  2098  ; and  of  these  226  died,  or  1 in  9. 
“ I think,”  writes  Mr.  Holmes,  “ no  unprejudiced  person  would 
hesitate  to  admit,  what  for  my  own  part  I firmly  believe,  that  the 
mortality  from  all  causes  in  the  country  is  higher  than  this  list 
shows.” 

On  the  contrary,  I submit  that  any  such  belief  on  Mr.  Holmes’s 
part  is  simply  and  purely  the  effect  of  prejudice ; and,  for  one,  I do 
not  wonder  at  it  in  a London  surgeon,  seeing  that  in  the  metro- 
politan hospitals  the  mortality  which  he  witnesses  is,  to  use  Mr. 
Holmes’s  words,  so  “evidently  enormous.”  I feel  assured  that  any 
unprejudiced  mind  must  come  to  an  opposite  conclusion  to  Mr. 
Holmes;  for  we  find  from  his  own  amputation  statistics  and  table ^ — 
and  altogether  contrary  to  his  own  prejudices  too — that  this  mor- 
tality is  so  far  regulated  by  the  size,  etc.,  of  the  hospitals,  as  to  vary 
as  follows : — 


In  metropolitan  hospitals  he  makes  it 
In  provincial  ,,  „ 

In  rural  „ „ 

And  in  the  smallest  of  these  hospitals 


1 in  3-3  * 
1 in  4 
I in  5‘4 
1 in  6, 


where  the  beds  were  100  or  less,  as.  I have  previously  shown  from  Mr. 
Holmes’s  own  statistics  in  the  discussion  of  Proposition  H.  But  if 
the  mortality  decreases  thus  with  the  segregation  of  the  patients, 
would  any  “ unprejudiced  ” mind  not  expect  it  to  be  still  more 
decreased  when  the  place  was  a cottage  hospital  with  25  beds ; or 
' where  the  isolation  of  the  patient  was  more  complete,  as  when  the 
operation  was  performed  in  single  rooms  in  country  and  provincial 
practice  ? 

Swayed  by  his  prejudices  against  the  far  greater  success  of  limb- 
amputations  in  single  rooms  in  the  country  than  in  the  wards  of  a 
large  London  hospital,  Mr.  Holmes  declares  it  as  his  “ conviction, 
from  reading  Sir  J.  Simpson’s  figures,  that  his  list  is  composed  of 
returns  from  surgeons  who,  having  been  gratified  by  their  success  in 
the  emergencies  of  practice,  have  treasured  up  records  of  that  suc- 

^ See  the  table  in  the  Official  Report,  p.  558. 

^ I have  shown,  from  more  ample  and  accurate  data  than  those  that  Mr. 
Holmes  used,  that  the  death-rate  from  the  four  major  amputations  in  the  London 
hospitals,  instead  of  being  1 in  3 ’3,  is  as  high  as  1 in  2 ’5  on  an  average,  and  that 
this  average  varies  only  by  two  or  three  decimal  points  in  the  four  largest  London 
hospitals. 


362 


HOSPITALISM  : 


cess,  and  been  glad  to  communicate  it.  Nothing,”  Mr.  Holmes  adds, 
“ can  be  more  natural,  nothing  more  legitimate  than  this.”  But  let 
me  remind  Mr.  Holmes  of  one  little  fact  which  is  quite  subversive  of 
this  ethical  theory  of  his.  The  names  of  the  contributing  “ surgeons  ” 
were  not  published  with  these  returns  ; and  they  have  not  been 
spoken  of  by  name,  unless  when  their  returns  contained  superadded 
“ remarks  ” which  seemed  to  me  to  be  deserving  of  citation  for  some 
purpose  or  another.^  There  was  in  this  way  none  of  the  self-grati- 
fication to  be  thus  obtained  which  Mr.  Holmes  thinks  so  natural 
and  legitimate  an  object.  But  even  if  it  were  otherwise,  would  that 
have  interfered  with  the  accuracy  of  the  country  returns  themselves  ? 
Have  not  some  hospital  returns  been  published  in  London  and  else- 
where for  this  same  ethical  reason  of  Mr.  Holmes  1 But  are  they 
the  less  valuable  on  that  account? 

But  further,  in  relation  to  this  fourth  objection — namely,  “ that 
the  comparison  between  hospital  and  country  amputations  is  ‘ unfair,'  for 
the  success  of  the  country  amputations  is  represented  as  too  high  ” — Mr. 
Holmes  selects  four  of  my  country  returns,  being  Nos.  92,  171,  191, 
and  288  in  the  published  table,  as  to  him  specially  questionable. 
Apparently  with  some  view  of  detracting  from  the  statistical  value 
of  these  returns,  Mr.  Holmes  observes  that  they  “ show,  when  taken 
together,  no  fewer  than  125  amputations  of  all  the  limbs  for  injury 
— the  thigh  having  quite  its  fair  proportion — occurring  in  the  prac- 
tice of  four  surgeons,  and  comprising  their  entire  experience,  ivithout 
a single  death."  Here  there  is  a grave  and  serious  error  on  Mr. 
Holmes’s  part,  made,  I have  not  the  slightest  doubt,  quite  inadver- 
tently and  not  willingly,  yet  forming  a very  great  and  reprehensible 
misstatement  in  such  a discussion  as  the  present.  These  four 
gentlemen  have,  according  to  their  own  certified  and  written  testi- 
mony, amputated  for  injury  in  125  cases;  but  2 of  the  patients 
died,  as  explicitly  shown  in  the  table  from  which  Mr.  Holmes  takes 
his  data.  The  same  four  practitioners  have  performed  amputation, 
as  pointed  out  in  the  same  table,  upon  137  cases  in  all,  5 of  which 
died,  or  1 in  27.  If  fortunate  in  their  operations  for  injuries,  they 
were  not  so  in  their  operations  for  disease ; as  they  lost  3 out  of 
their  12  pathological  amputations,  or  1 in  4. 

^ Mr.  Holmes  might  have  taken  out  of  the  list  other  returns  amounting  to 
nearly  the  same  number,  as  Nos.  13,  149,  194,  227,  and  in  which  four  returns  the 
number  of  amputations  reported  is  128.  Out  of  these  128  amputations  25  died, 
or  1 in  5.  Should  these  four  returns  therefore  be  discarded  as  too  low  ? The 
eight  I’eturns,  92,  171,  191,  288,  13,  149,  194,  and  227,  when  added  together,  give 
30  deaths  out  of  2G5  amputations,  or  1 death  in  every  8 or  9 operated  upon- -the 


PROPOSITIONS  ON. 


363 


Does  Mr.  Holmes  really  mean  to  argue  that  I should  not  have 
included  those  125  primary  cases,  because,  in  his  opinion,  they  were 
too  successful  ? And,  on  the  same  ground,  should  I have  rejected 
the  high  mortality  met  with  by  the  same  four  surgeons,  in  their 
amputations  for  disease,  because  it  was  greatly  above  the  usual 
mortality?  The  chief  value  of  any  statistical  inquiry  like  the 
present  consists  in  taking  in  all,  extreme  as  well  as  all  intermediary, 
numbers,  and  striking  an  average  or  mean  out  of  the  whole.  What 
would  be  thought,  for  example,  of  a statistician  who,  in  striking  the 
mean  mortality  of  any  population  for  a given  time,  objected  to 
admitting  among  his  data  all  who  died  after  seventy  years  of  age  or 
before  five  years?  Mr.  Holmes  doubts  whether  any  such  success  is 
possible  ” to  be  attained  in  hospital  practice.  Now  in  St. 
Bartholomew’s  Hospital  in  London  in  1855,  17  males  suffered 
amputation,  and  all  recovered.  During  the  same  year,  in  25  ampu- 
tations, 12  of  which  were  thigh  cases,  there  was  only  one  death. 
In  1861  there  were  24  consecutive  amputations  with  only  1 fatal 
case.  In  this  way,  in  that  metropolitan  hospital,  during  these 
periods,  out  of  49  limb-amputations  only  2 died,  or  about  1 in  25. 
But  the  reporter,  Mr.  Callender,  shows  “ how  necessary  it  is  to  mass 
together  a considerable  number  of  consecutive  operations  before  we 
have  a chance  of  arriving  at  tolerably  just  conclusions.”  ‘ For  in 
1863  to  the  end  of  September  there  were  13  deaths  to  28  recov^eries 
after  amputation  in  St.  Bartholomew’s:  in  1858  and  1863  there 
were  5 and  8 consecutively  fatal  cases.  At  the  present  time,  and 
for  some  years  past,  the  death-rate  after  amputations  at  St.  Bartholo- 
mew’s is  as  high  as  1 in  2*7,  instead  of  1 in  25.  Great  runs  of 
success  in  this  way  are  not  unfrequent  in  other  hospitals,  both  sur- 

ifeual  mortality  in  country  amputations.  Mr.  Holmes  thinks  that  the  occurrence 
of  such  success  as  the  four  country  practitioners  in  the  text  met  with,  would,  ‘ ‘ in 
the  practice  of  four  hospital  surgeons  ” — as,  for  example,  the  four  surgeons  of  St. 
George’s  Hospital — “ be  nothing  less  than  ^miraculous.’”  It  would  of  course  be 
so  unless  the  insalubrious  conditions  of  St.  George’s  Hospital  were  totally 
changed  ; and  it  would  be  so  in  another  sense  truer  than  Mr.  Holmes  imagines. 
The  four  returns  are  selected  by  him,  I believe,  as  being  the  four  best  in  the  total 
series  of  374.  There  are  perhaps  nearly  an  equal  number  of  hospital  surgeons  in 
England  ; and  let  us  suppose  them  to  be  374  also.  Now  Mr.  Holmes,  or  any  of 
the  other  four  surgeons  of  St.  George’s,  might  certainly  have  a fair  prospect  of 
being  one  of  the  four  successful  surgeons  out  of  the  374,  if  the  hospital  conditions 
were  duly  changed  for  the  safety  of  the  patients  ; but  the  idea  of  all  “ the  four 
surgeons”  of  St.  George’s  standing  at  the  head  of  the  374  is  a result  which,  in  the 
calculation  of  chances,  is  as  millions  to  one — something  more  truly  “miraculous” 
than  Mr.  Holmes,  perhaps,  dreamt  of  when  he  penned  the  sentence. 

^ See  Medico-Chirurcjical  Transactious,  vol.  xlviii.  p.  95. 


364 


HOSPITALISM  : 


gical  and  obstetrical,  as  well  as  in  country  practice,  where,  from  the 
death-rate  being  so  small  and  pyaemia  so  much  rarer,  it  is  much  more 
likely  to  occur.  But  the  Nemesis  of  figures  always  at  last  certainly 
and  ruthlessly  reduces  the  statistics  to  their  proper  mean  when  the 
numbers  become  sufficiently  large.  For  here,  as  elsewhere  in  such 
statistical  inquiries,  while  there  is  always  a great  uncertainty  and 
instability  in  regard  to  the  results  of  a small  and  limited  number  of 
cases,  a larger  and  larger  aggregation  of  cases  comes  to  afford  con- 
clusions which  are  comparatively  certain  and  stable.^  In  a return 
which  was  sent  to  me  last  week,  by  Dr.  Strange,  of  the  mortality  of 
limb-amputations  in  the  Worcester  Hospital,  I find  that  since  1862, 
22  cases  of  primary  amputation  of  the  leg,  and  8 cases  of  primary 
amputation  of  the  arm,  or  30  in  all,  were  performed  in  the  hospital 
in  question  without  a single  death.  That  most  excellent  surgeon, 
Mr.  Carden,  when  first  describing  his  new  form  of  flap-amputation, 
reported  17  hospital  cases  in  succession  of  thigh -amputation  for 
disease  without  a single  death ; but  he  had  3 1 other  amputations  in 
all,  and  out  of  the  remaining  1 4 cases  5 died,  or  above  1 in  3.  In 
the  first  30  amputations  for  disease  in  the  Glasgow  Infirmary,  Dr. 
Lawrie  tells  us,  only  1 died.  Now,  in  that  same  hospital,  they  lose 
1 in  every  3 in  their  amputations  for  disease.  At  the  Leeds  meet- 
ing of  the  British  Medical  Association,  Dr.  George  Macleod  of 
Glasgow,  a most  able  and  skilful  surgeon,  reported  the  result  of  50 
amputations  of  the  ankle-joint  which  he  had  performed.  Only  1 
out  of  the  50  died.  But  in  the  statistics  of  the  Glasgow  Infirmary, 
which  are  kept  with  most  commendable  accuracy,  I find  that  out  of 
the  last  50  cases  operated  on  in  the  hospital,  10  of  the  patients  sank, 
or  1 in  5.  The  York  hospital  is  specially  adverted  to  by  Mr. 
Holmes,  in  his  excellent  Official  Report,  as  at  one  time,  from  want  of 

^ Elsewhere  I have  tried  to  show,  at  some  length,  that  the  great  and  leading 
prineiple  upon  which  statistical  inquiry  is  grounded  consists  in  the  fact  that  in 
unities  or  entities  of  a doubtful  chance,  while  the  result  or  event  in  individual 
instances  is  ever  variable  and  uncertain,  the  result  and  event  when  calculated 
from  or  upon  masses  of  instances  becomes  comparatively  certain  and  invariable. 
(See  Edinburgh  Monthly  Journal  of  Medical  Science,  Nov.  1847.)  Perhaps  one  of 
the  most  remarkable  instances  of  a statistical  death-rate  becoming  rectified  by 
increased  numbers  is  that  of  Mr.  Martineau  of  Norwich.  In  the  eleventh  volume 
of  the  Transactions  of  the  Medico-Chirurgical  Society  of  London,  Mr.  IMartineau 
published  an  account  of  74  cases  in  which  he  had  performed  the  operation  of 
lithotomy  in  the  Norwich  Hospital,  from  the  year  1804  to  1840.  Only  2 of  these 
74  died  ; or  1 in  37.  We  learn  further,  however,  from  a paper  by  Dr.  Yellowly, 
that  jMr.  IMartineau  operated  in  the  same  hospital  on  73  additional  cases,  or  147 
in  all.  Of  these  73  additional  cases,  15  died  ; or  more  than  1 in  5. 


PROPOSITIONS  ON. 


365 


ventilation,  suffering  under  “ an  extreme  degree  (as  regards  surgical 
patients)  of  hospital  unhealtliiness  ” (p.  549).  It  is  now  greatly 
improved ; and  during  the  years  1867  and  ’68,  out  of  24  limh-ampu- 
tations  performed  within  it,  only  1 patient  died.  Perhaps  it  may 
not  be  out  of  place  to  add  here,  that  since  publishing  my  table  of 
country  amputations  in  March  1869,^  I have  been  told  of  various 
country  practitioners  who  have  performed,  with  remarkable  success, 
larger  numbers  of  limb -amputations  than  any  that  were  at  that 
time  reported  to  me. 

Secondly,  Mr.  Holmes,  in  addition,  states  and  argues  that  my 
table  of  country  amputations  contains  only  two  leading  sets  of 
operations — viz.,  in  the  returns  (1)  of  those  who  had  great  experience 
and  much  practice  in  amputations,  and  (2)  of  those  who  had  very 
few  operations  to  return.  As  shown  in  Proposition  IV.,  this  is 
scarcely  the  fact,  as  out  of  the  2098  cases  reported,  821  of  the  cases 
were  performed  by  surgeons  who  had  amputated  twelve  times  or 
oftener;  648  of  them  by  practitioners  who  had  operated  from  six 
to  twelve  times,  and  629  by  country  medical  gentlemen  who  had 
operated  five  times  or  less.  Surely  this  is  an  equal  enough  division, 
even  to  satisfy  Mr.  Holmes. 

But,  thirdly,  he  professes  to  have  another  objection  to  my  table 
of  country  amputations,  by  which  he  thinks  the  success  in  it  is  also 
made  too  high;  I have  given,  he  avows,  as  one  kind  of  returns, 
“ very  small  numbers  of  amputations  for  disease,  in  many  instances 
single  cases,  which  have  almost  uniformly  proved  successful.”  This, 
I humbly  submit  to  Mr.  Holmes  himself,  is  very  wrong.  He  will 
find  in  the  table  of  returns  eight  or  nine  reports,  at  least,  of  one  or 
two  cases  only  in  which  the  amputations,  instead  of  being  repre- 
sented, as  he  avows,  as  “ uniformly  successful,”  are  returned  as  uni- 
formly fatal.  The  table  contains,  on  the  whole,  71  returns  of  cases 
in  which  the  practitioner  had  only  performed  amputation  once.  Of 
these  cases,  23  were  forearm-amputations,  and  therefore  accompanied 
in  the  country  with  little  or  no  danger.  Of  the  remaining  48,  as 
many  as  7 of  the  cases,  or  I in  7,  are  reported  as  fatal ; of  the 
whole,  about  1 in  10  died.  Should  not  Mr.  Holmes  at  once  retract 
this  with  his  other  objections,  as,  to  use  his  own  word,  “ unfair  ”P 

^ See  Chapter  I. 

2 An  excellent  young  practitioner  — Mr.  Cribbes  of  Gorebriclge  — whose 
remarks  Mr.  Holmes  quotes  as  those  of  “ very  probably  one  of  the  (four)  surgeons  ” 
spoken  of  in  the  text,  belonged,  not  to  that  class,  but  to  the  present  class  of 
practitioners,  who  had  returned  one  amputation.  Mr.  Holmes  erroneously  makes 


366 


HOSPITALISM  : 


Objection  V.  “ I assert,'  says  Mr.  Holmes,  “ that  such  a compari- 
son  as  Sir  James  Simjmn  has  made  between  private  and  hospital  prac- 
tice must  always  he  unfair,  because  the  cases  are  selected  on  different 
principles  in  private  practice"  from  ivhat  they  are  in  hospital  practice. — 
“ The  fact  (he  adds)  must  be  as  I say,”  for,  to  quote  his  own  words, 
“ hospital  surgeons  refuse  nothing  in  the  way  of  operation  which 
comes  to  their  hands.”  ^ On  the  contrary,  I feel  and  hope  that,  in 
the  main,  this  argument  is  merely  an  illusion  on  Mr.  Holmes’s  part. 
It  would,  indeed,  be  painful  and  revolting  to  most  professional 
minds  even  to  suppose  that  the  poor,  who  form  the  patients  in  our 
rich  hospitals,  were  cut  and  operated  upon  by  hospital  surgeons  on 
principles  different  from  those  on  which  patients  were  treated  out  of 
hospital.  Dr.  Broth erston  of  Alloa,  who  has  performed  above  sixty 
amputations  of  the  limbs,  has  already  rather  indignantly  criticised 
Mr.  Holmes’s  remarks  on  this  point.^  There  is,  he  observes,  “ cer- 
tainly not  one  rule  for  hospital  patients  and  another  for  private 
patients.  The  very  idea  is  Avrong.  The  operations  in  the  country 
are  as  serious  and  difficult  as  in  the  town,  and  the  number  of  pri- 
maries as  large  or  larger.  Arms  and  legs  are  saved  in  the  country 
that  would  have  been  amputated  in  town  [hospitals].  The  joints, 
etc.,  heal  in  the  country,  aided  by  uncontaminated  air  and  proper 
treatment.” 

For  his  strange  belief  in  the  present  objection  Mr.  Holmes  offers 
two  reasons.  First,  he  observes,  “ the  private  practitioner  Avould  very 
rarely  be  permitted  to  perform  such  a grave  operation  as  an  ampu- 
tation, unless  he  could  hold  out  much  more  confident  hopes  of  suc- 
cess than  any  candid  man  could  do  in  many  of  the  amputations 
which  we  perform”  (but  which  he  certainly  can,  as  his  amputations 
are  three  times  more  successful  than  those  of  the  city  hospital  sur- 
geons) ; and,  secondly,  “ there  is  always  the  habit  Avhich  the  poor 
have  in  doubtful  and  grave  cases  of  seeking  the  advice  of  the  hospital 
surgeons.” 

Mr.  Holmes  appears  to  fancy  that  in  the  country  everything 
goes  on  exactly  as  in  London.  But  in  many  country  districts  in 

him  testify  against  the  presence  of  “tetanus”  in  mining  poj)ulations.  But  raost 
certainly  Mr.  Cribbes  does  not  commit  himself  in  any  such  Avay.  Out  of  the 
deaths  in  country  practice  which  I have  collected,  10  or  11  Avere  from  tetanus. 
(See  Chapter  II.  p.  311.) 

^ In  Chapter  II.  p.  320,  I have  quoted  several  cases,  and  have  heard  of  others, 
where  patients  sent  out  of  hospital  underAvent  amputation  and  recovered.  Dr. 
Philip  Maclagan  of  Ilei-wick  told  me  of  a case  lately  occurring  to  himself. 

" See  Medical  Journal  for  March  6,  1869. 


PROPOSITIONS  ON. 


367 


Great  Britain  where  amputations  are  performed,  and  performed 
frequently,  especially  for  injuries,  Mr.  Holmes  forgets  that  there  is 
often  no  hospital  surgeon  sufficiently  near  to  consult  in  a case  of 
shattered  limb,  and  they  would  have  to  wait  six,  twelve,  twenty- 
four  hours  or  more,  to  get  an  hospital  surgeon  ; and  in  some  country 
districts — in  Scotland  at  least,  and  I could  name  some  in  England 
too — there  is  no  desire  to  consult  them  even  when  within  reach,  as 
the  patients  frequently  rather  dread  hospitals,  and  have  the  most 
full  and  implicit  confidence  in  their  own  local  practitioners.  The 
number  of  cases  of  limb-amputations  which  I have  collected  from 
country  practitioners  are  surely  sufficient  to  gainsay  Mr.  Holmes’s 
strange  assertion,  “ that  they  are  very  rarely  permitted  to  perform 
such  a grave  operation.”  The  country  surgeon  no  doubt  sometimes 
meets  with  opposition  at  first — at  least  at  the  idea  of  amputation ; 
but  perhaps,  after  all,  not  much  oftener,  if  oftener,  than  the  hospital 
surgeon.^ 

Mr.  Holmes  holds  that  there  are  some  causes  which  of  late  have 
increased  the  mortality  of  amputations  in  large  hospitals.  For  we 
may  state  it  as,  on  his  part,  another 

Objection  VI.  In  hospitals,  conservative  surgery  increases  our  hos- 
pital “ mortality  after  amputations  hy  withdrawing  all  the  letter  or  more 
hopeful  classes  of  cases  entirely  from  the  amputatorl — Mr.  Holmes  here 
refers  particularly  to  the  excision  of  diseased  joints,  instead  of 
amputation  of  the  limb.  “ Consequently,”  he  argues,  “ as  surgery 
improves,  the  rate  of  mortality  after  amputation  tends  to  increase. 
If  it  be  true,”  he  continues,  “ that  in  the  provinces  practice  inclines 
more  to  the  old  than  the  modern  methods,  this  would  tend  to 
increase  the  success  after  amputation  in  the  country.  This,”  he 
adds,  “ is  a matter  wdiich  cannot  be  dealt  with  by  figures! 

But  I doubt  this  last  allegation  of  Mr.  Holmes’s ; for  statistics 
seem  to  me  to  be  able  to  prove  by  their  figures  that  any  such 

^ AVheii  lately  visiting  a patient  at  Coniston  with  ]\Ir.  ByAvater,  that  gentle- 
man told  me,  in  the  course  of  conversation,  that  he  had  ])erformed  many  limh- 
ampiitations  ; and  he  had  lost  only  one  patient  amongst  them,  a case  of  gangrene 
of  the  arm.  On  putting  to  him  Mr.  Holmes’s  hypothetical  objection  about  the 
supposed  difficulty  of  getting  country  patients  to  submit  to  amputation,  he  told 
me,  in  reference  to  one  of  his  earliest  amputations,  that  he  was  at  fust  asked  to 
do  the  operation  without  seeing  the  case,  a message  being  merely  left  for  him  to 
bring  forthwith  his  “tools”  with  him  to  a patient,  as  she  wanted  her  leg  to  be 
lopped  otf.  Here  the  patient  and  her  friends  Avished  to  decide  the  (Question 
without  asking  at  all  the  aid  of  the  surgeon  as  to  the  mere  propriety  of  the 
operation. 


368 


HOSPITALISM : 


changes  exert  less  influence  than  he  imagines  in  increasing  the 
hospital  death-rate  after  amputations. 

Thus,  in  the  Glasgow  Infirmary,  from  its  opening  in  the  last 
century  in  1794  to  the  end  of  1838,  the  death-rate  in  limb-ampu- 
tations was,  according  to  the  researches  of  Professor  Lawrie,  1 in 
2’7 ; ^ but  from  1860  to  1868  the  death-rate  was  very  nearly  the 
same,  or  as  1 in  2*5.’ 

In  the  Edinburgh  Infirmary,  during  three  years  and  a half,  Dr. 
Fenwick,  writing  in  1848,  calculated  the  mortality  of  the  limb- 
amputations  to  be  1 in  1*96.  During  the  last  eight  or  ten  years  it 
has  been  rather  diminished  tlian  increased,  being  1 in  2*3.^ 

I am  not  aware  of  the  existence  of  any  London  hospital  ampu- 
tator’s  statistics  a quarter  or  half  a century  old  by  which  we  could 
test  the  idea  that  in  hospitals,  after  amputation,  the  mortality  is 
increasing ; but  the  preceding  data  scarcely  favour  that  opinion. 

Objection  VII.  comparison,”  says  Mr,  Holmes,  ^'between 
perfect  Hiospital]  and  imperfect  \_private  country']  returns  must  he  de- 
lusive.”— Is  in  reality  the  one  form  of  the  return  thus  more  highly 
reliable  than  the  other  1 Do  the  hospital  returns  contain  more 
perfectly  authentic  data,”  as  I have  heard  earnestly  insisted  on  by 
various  parties  1 

It  would  very  ill  become  me,  as  one  who  has  received  so  much 
kindness  and  aid  in  this  inquiry  from  professional  brethren  con- 
nected with  the  hospitals  of  Great  Britain,  to  comment  upon  this 
matter.  But  I may  be  permitted,  perhaps,  to  state,  that  from  a 
considerable  number  of  hospitals  I have  received  no  reply ; from 

^ See  Medical  Gazette  for  December  1840,  p,  397. 

2 See  Table  V. 

^ According  to  the  official  returns  of  the  last  two  years — embracing  the  time 
since  antiseptic  dressings,  etc.,  were  profusely  introduced  in  most  of  the  wards 
— the  amputation  mortality  of  the  Edinburgh  Infirmary  has  increased  to  above  1 
in  2.  From  1859  to  1866  it  was  1 in  2'5.  In  1867  and  1868  it  was  1 in  1*8,  or 
had  risen  from  40  per  cent  of  those  operated  upon  to  53*6  per  cent.  In  his  work 
on  Carbolic  Acid  (1863  and  1865,  2d  edit.,  p.  364),  Dr.  Lemaire  of  Paris,  Dr. 
Declat,  and  others,  taught  that  pyeemia  in  surgical  wards  could  be  prevented  by 
the  use  and  emanations  of  carbolic  acid.  (See  The  Lancet  for  September  2,  1867, 
p.  547.)  'During  the  several  years  from  1861  downwards,  while  M.  Maisonneuve 
used  carbolic-acid  dressings  in  his  wards  in  the  Hotel  Dieu  (which  he  has  now,  I 
believe,  abandoned  for  alcoholic  and  other  applications),  it  was  not,  I am  aware, 
observed  that  there  was  any  diminution  of  i)yjemia  among  his  patients.  But  the 
attempt  to  dimin?oh  it  and  other  diseases  which  has  been  made  from  time  to  time 
by  sulphur-fumes,  chlorine,  euchlorine,  carbolic  acid,  ozone,  cressol,  etc.,  and 
other  disinfectants  and  antisejotics,  is  certainly  a line  of  inquiry  well  wortli 
further  investigation. 


PROPOSITIONS  ON. 


369 


professional  officers  connected  with  others  I have  been  told  that  it 
was  useless  to  apply,  as  no  authentic  records  of  the  kind  required 
were  in  existence ; and  from  various  quarters  I have  been  informed 
of  the  doubts,  the  difficulties,  and  the  impossibilities,  of  filling  up 
the  schedules.  But  I believe  the  British  returns  which  I have  now 
collected  and  summarised  contain  a fair  and  reliable  account  of  the 
limb-amputations  belonging  to  each  hospital  in  the  list.  I willingly 
leave  any  criticisms  on  this  point  to  the  distinguished  officer  of  the 
Privy  Council,  Mr.  Simon,  who,  five  years  ago,  in  his  preface  to  the 
published  Keport  of  Mr.  Holmes  and  Dr.  Bristowe,  speaks  of  the 
“ present  grievous  imperfectness  of  hospital  statistics”  as  impeding 
in  England  the  comparison  of  the  success  and  healthiness  of  English 
hospitals  with  each  other ; and  he  observes,  as  the  result  of  the 
experience  of  Mr.  Holmes  and  Dr.  Bristowe,  that,  “ in  the  vast 
majority  of  hospitals,  no  scientific  records  were  kept ; and,  in  the 
rare  instances  where  reasonably  good  records  were  seen,  these,  as 
kept  at  different  hospitals,  were  commonly  so  unlike  to  each  other 
that  no  exact  or  minute  comparison  between  them  could  be  made” 
(pp.  31  and  38).  This  was  written  in  18G4.  During  the  last  few 
years  matters  in  this  respect  have,  I believe,  become  greatly  changed 
for  the  better. 

On  the  contrary,  are  not  the  country  amputation  returns  more 
authentic  and  reliable  ? I believe  that  they  are  so  for  more  than 
one  reason.  In  the  country  returns  the  schedules  were  usually 
filled  in,  and  their  accuracy  always  authenticated  and  attested  by 
the  signature  of  the  operating  surgeon.  In  the  hospital  returns  the 
schedules  were  most  usually  signed  by  the  house-surgeon,  or  by  one 
of  the  professional  staff  of  the  hospital.  In  the  country  returns, 
the  signatures  have  a personal  responsibility  for  accuracy  ; while,  on 
the  ccnitrary,  in  the  hospital  returns,  the  signatures  have  only  a cor- 
porate  responsibility  attached  to  them — a point  of  some  difference 
in  relation  to  perfect  legal  authenticity.*  The  accuracy  of  the  country 
data,  as  reported  to  me  by  the  374  country  surgeons,  is  proved,  I 
repeat,  by  the  fact  that  they  are  all  duly  and  personally  attested  by 
the  returning  operators.  If  a man  had  a few  cases  only  of  amputa- 

^ This  difference  seems  to  have  been  felt  strongly  by  some  that  returned  the 
hospital  schedules.  Thus,  in  one  of  the  last  sent  in  to  me,  from  a large  hospital 
in  England,  the  house-surgeon  does  not  adhibit  his  signature,  but  conscientiously 
remarks  that,  being  lately  installed,  he  had  merely  extracted  the  cases  from  the 
operation  book.  “ For  its  accuracy,’"'  he  adds,  “ I would  rather  not  own  any 
responsibility  ; perhaps  some  cases,  successful  or  not,  have  been  omitted  by 
chance.” 


370 


HOSPITALISM  : 


tion  in  the  course  of  his  practice,  he  was  of  course  sure  to  remember 
them  as  so  many  white  stones  placed  along  the  pathway  of  his  pro- 
fessional life  ; those  that  had  more  had  sufficient  entries  and  notes 
to  guide  them.  But  I failed  in  obtaining  specialised  returns  from 
several  practitioners,  who  had  performed  a large  number  of  ampu- 
tations, because  they  had  kept  no  records  of  the  peculiarities  and 
results  of  their  operations.  Further,  that  the  country  returns  pre- 
sent a fair  mean  in  showing  1 death  in  9 is,  to  my  own  mind,  proved 
by  the  fact  that  when  the  schedules  were  collected,  and  summed 
up  from  time  to  time  by  my  assistants.  Dr.  Aitken  and  Dr.  Munro, 
they  kept  on  the  whole  near  this  figure,  though  sometimes  the 
general  mean  ran  higher  than  1 in  10,  and  again  lower  than  1 in 
8.  When  I collated  and  summarised  above  2000  cases,  I ceased 
from  extending  the  collection ; believing  I had  brought  together 
enough  for  a satisfactory  and  reliable  mean,  and  believing  also  that 
in  no  question  connected  with  amputation  statistics  had  so  large  a 
body  of  data  ever  before  been  deemed  necessary. 

Objection  VIII.  The  private  cases  of  amputation  in  hospital 
cities  and  towns  should  have  been  collected. — “ If,”  observes  Mr.  Holmes, 
“ Sir  J.  Simpson  had  not  been  so  scrupulous  to  compare  things  which 
are  dissimilar,  if  he  had  not,  as  he  says  he  did,  in  selecting  the 
practitioners  to  whom  the  applications  and  schedules  were  sent, 
avoided  as  far  as  possible  including  in  the  list  any  members  of  the 
profession  residing  in  our  large  hospital  cities  and  towns  [«s  my 
object  was  to  obtain  the  returns  principally  from  country  and  provincial 
professional  his  eyes  would  have  been  opened  to  the  fact  that, 
in  order  to  test  the  effects  of  hospital  arrangements  upon  cases,  the 
cases  themselves  must  be  otherwise  under  similar  circumstances.” 

In  this  quotation  I have  restored,  in  brackets  and  italics,  an 
important  passage  which  Mr.  Holmes  has  omitted,  because  it 
shows  that  my  object  was  to  compare  the  results  of  amputation 
upon  patients  in  our  large  hospitals  with,  as  far  as  possible,  socially 
the  same  class  of  patients  in  the  country.  As  far  as  I can  under- 
stand the  object  of  Mr.  Holmes’s  remarks,  I should  also  have  applied 
for  and  collected  private  amputation  returns  from  towns  and  cities 
in  which  hospitals  existed.  I asked  for  them  many  months  ago,  in 
the  British  Medical  Journal  for  January  1869,  but  have  received  none. 
If  they  were  brought  together,  they  would  scarcely  afford,  I fear,  a 
fair  and  just  comparison  with  hospital  returns  ; as  the  latter  would 
include  the  results  of  operations  upon  the  poor,  the  other  upon  the 
rich  ; for  in  towns  and  cities  with  hospitals  the  poor  become,  almost 


PROPOSITIONS  ON. 


371 


all,  for  operative  procedures,  tlie  inmates  of  the  hospitals.  Surely 
Mr.  Holmes  himself  could  scarcely  expect  me  to  find  the  hospital 
town  amputation  returns  which  he  desiderates.  For  he  observes  : 
“ Almost  all  grave  surgical  cases  among  the  poor  in  London  are  re- 
moved to  hospitals.”  And  if  this  happen  in  London,  let  me  ask 
Mr.  Holmes  how  or  why  he  expects  it  to  he  different  in  other  hos- 
pital cities  and  towns  1 One  of  the  greatest  and  most  celebrated 
surgeons  of  the  present  day.  Professor  Billroth,  of  Vienna,  lately 
wrote  me  that  he  had  never  yet  had  an  amputation  in  private  prac- 
tice. How  many  has  Mr.  Holmes  himself  had,  and  what  Avas  their 
result  1 

To  the  statement  that  the  death-rate  after  limb-amputations  is 
three  times  more  excessive  in  the  Avards  of  our  large  and  metropolitan 
hospitals  than  in  single  rooms  in  private  country  practice,  one  or  tAvo 
additional  points  of  opposition  have  been  raised — chiefly,  hoAvever, 
by  others,  more  than  by  Mr.  Holmes.  It  has  been  especially  sug- 
gested and  averred  that  the  class  of  cases  operated  upon  by  the 
hospital  surgeon  must  be  more  perilous  than  the  class  of  cases 
operated  upon  by  the  country  surgeon  ; that  the  state  of  the  patients 
at  the  time  of  operating  must  be  more  desperate  and  unfavourable 
in  infirmary  urban  than  in  private  rural  practice ; that  the  nature 
of  the  causes  leading  to  the  amputations  must  be  more  serious  in 
the  former  than  in  the  latter  class  of  patients ; and  that  altogether 
the  operations  must  be  radically  of  a more  dangerous  and  fatal  kind 
in  large  hospital  practice  than  in  prh'ate  country  practice.  For 
none  of  these  arguments  against  the  comparison  of  hospital  and 
country  amputations  is  there,  I believe,  any  just  foundation.  Of  the 
two  classes  of  limb-amputations — those  (1.)  for  diseases  and  (2.)  for 
injuries — there  is  not  a particle  of  evidence,  as  far  as  I am  aAv^are,  to 
shoAV  that  in  severity  and  danger  the  pathological  amputations  in 
the  country  differ  in  any  respect,  in  causation  or  otherAvise,  from  the 
pathological  amputations  in  the  hospitals.  On  the  large  scale,  any 
100  of  the  one  are  on  a par  with  any  100  of  the  other.  But  the 
question  is  different  with  amputations  for  injury  ; for  in  this  trau- 
matic class  all  the  chief  points  are  much  more  easy  of  comparison, 
and  all  the  relative  questions  of  hospital  and  country  practice  much 
more  readily  studied  and  solved.  For  instance,  Ave  may,  in  refer- 
ence to  them,  lay  doAvn  the  following  observation  as — 


372 


HOSPITALISM  : 


Proposition  XIL — The  country  amimtations,  though  far  more  success- 
ful, ought  to  he  more  'perilous  and  fatal  than  the  hospital  amputations, 
inasmuch  as  they  contain  a marked  excess  of  amputations  for  injury  ; 
tchicli  traumatic  amputations  are  more  dangerous  than  amputations 
for  disease. 

It  is  a well-known  circumstance  in  surgical  statistics  that 
amputations  for  injury  are,  on  the  large  scale,  much  more  fatal  than 
amputations  for  disease.  The  writings  of  Phillips,  Lawrie,  Malgaigne, 
Steele,  Hayward,  Norris,  Gross,  and  various  other  writers,  all  contain 
abundant  proofs  of  this  fact.  In  the  2089  cases  which  I have  pub- 
lished in  Chapter  II.,  collected  from  large  and  metropolitan  British 
hospitals,  1022  were  amputations  for  injury,  and  1067  for  disease. 
Of  the  former  48  per  cent  died  ; of  the  latter  only  34  per  cent ; or 
14  in  the  100  more  died  after  traumatic  than  after  pathological 
amputations.  In  the  Glasgow  Hospital  returns,  published  by  Dr. 
Lawrie,  the  proportion  of  deaths  after  amputations  for  injury  was 
more  than  twice  as  great  as  it  was  after  dismemberment  for 
disease. 

It  was  at  first  repeatedly  suggested  to  me  that  country  amputa- 
tions would  be  found  to  be  chiefly  operations  for  disease,  and  that 
this  would  go  far  to  account  for  their  greater  success  over  hospital 
amputations.  “ We  all  know,”  writes  a London  hospital  surgeon  in 
the  Medical  Gazette  of  Jan.  23,  “ how  very  different  are  the  results  of 
amputations  for  injuries  and  of  amputations  for  disease.  Is  Sir  Jas. 
Simpson  prepared  to  show  that  these  two  classes  of  cases  were  in 
equal  proportions  in  the  two  classes  of  cases  which  he  compares  1” — 
namely,  those  belonging  to  large  hospital  practice  and  those  pertain- 
ing to  private  country  practice.  I am  prepared  to  show  that  the 
advantages  in  this  respect  are  all  in  favour  of  the  hospital  returns, 
and  the  very  reverse  of  what  this  writer  evidently  supposes. 

Of  the  2089  hospital  amputations,  1022,  as  just  stated,  Avere 
operations  for  injury.  Of  the  2098  country  amputations,  1382  Avere 
operations  for  injury,  and  716  for  disease ; or,  to  state  it  in  a more 
tabular  form — 

In  2098  country  amputations  . 1382  AA^ere  primary 


In  2089  hospital  „ 

. 1022  „ ^ „ 

r primary  amputa- 

Giving  thus  a surplus  of 

360  -<  tions  to  the  coun- 

\ try  returns. 

PROPOSITIONS  ON. 


373 


Such  an  excess  of  primary  or  traumatic  amputations  in  the 
country  returns  ought  to  have  weighed  heavily  against  the  chances  of 
success  of  the  country  operations,  and  no  doubt  did  so  to  some  ex- 
tent ; and  it  ought  to  have  weighed  correspondingly  in  favour  of  the 
hospital  returns.  Yet,  notwithstanding  these  advantages,  the  success 
on  the  whole  on  the  part  of  country  as  compared  with  hospital 
practices,  was,  as  we  have  seen,  more  than  three  to  one.* 

Repeatedly  I have  found  it  urged  as  an  objection  to  the  com- 
parison of  country  with  hospital  amputations,  that  possibly  the 
country  patients  were  not  so  exhausted  and  weakened  at  the  time 
of  operating  as  were  the  hospital  patients.  But  the  large  class  of 
primary  cases  at  once  offers,  as  an  argument  against  this  reasoning, 
the  following  proposition,  viz. — 

Proposition  XIIT. — The  state  of  the  imtients  at  the  time  of  operating 
in  these  (traumutic)  amputations  is  precisely  the  same  in  country 
practice  and  in  hospital  practice. 

For  the  amputations  in  this  class  for  injuries  being  necessitated 
by  accident,  the  patients  immediately  beforehand  must  be  held  as 
all  similar  in  their  state  of  strength  and  vital  force.  They  were  all 
alike  in  the  condition  of  ordinary  or  normal  health  a few  hours,  or 
a very  short  time  at  least,  before  the  operation  was  resorted  to. 

^ In  Edinhurgli  Medical  Journal,  December  1869,  Sir  J.  Y.  Simpson  wrote  : 
— “ In  other  points  there  is  an  advantage  of  the  contrary  kind  against  the  hospital 
and  in  favour  of  the  country  amputations.  For  example — 

“ The  hospital  amputations  contain  a greater  list  of  amputations  of  the  lower 
extremities  than  the  country  returns. — Of  the  2098  country  amputations,  1287 
were  amputations  of  the  lower  extremity,  and  811  were  amputations  of  the  upper 
extremity.  Of  the  2088  hospital  amputations,  1548  were  amputations  of  the 
lower  extremity,  and  541  were  amputations  of  the  upper  extremity.  But  the 
operation  is  much  more  fatal  in  the  thigh  and  leg  than  in  the  arm  and  forearm. 
In  the  returns  of  the  eleven  large  and  metropolitan  hospitals  included  in  Table 
XL  the  amputations  of  the  lower  extremity  proved  fatal  in  45  per  cent,  the 
amputations  of  the  upper  extremity  in  28  per  cent.  As  already  pointed  out  in 
Chapter  II.  1,  the  greater  number  of  amputations  of  the  forearm  and  arm  in 
country  practice  is  owing  to  the  greater  frequency  of  the  accidents  to  which  men 
are  exposed  in  country  life  from  gunshot  wounds,  and  from  the  injuries  produced 
by  the  unguarded  thrashing-machine  of  the  agriculturist.  In  the  country  returns 
there  are  811  amputations  of  the  upper  extremity  reported ; in  the  hospital  re- 
turns 541  amputations  of  the  upper  extremity  are  given.  There  is  a slightly 
larger  number  of  the  most  dangerous  amputation  of  all — viz.  of  primary  amputa- 
tion of  the  thigh — given  in  the  2098  country  than  in  the  2089  hospital  amputations ; 
but  the  latter  contains,  for  reasons  given  elsewhere,  a greater  number  of  thigh 
amputations  for  disease  ; — though  this  operation,  for  this  cause  is,  when  performed, 
nearly  three  times  more  successful  in  country  than  in  hospital  practice.”  [Ed.] 


374 


HOSPITALISM  : 


Frequently,  however,  the  hospital  surgeon  amputates  in  these 
cases  in  a less  dangerous  set  of  limb-injuries ; inasmuch  as  more 
cases  of  them  are  saved  from  the  amputating  knife  in  country  than 
in  hospital  practice.  For,  according  to  another  legitimate 

Proposition  XIV. — Primary  amputations  are  chiefly  for  the  worst 
forms  of  compound  fractures  of  the  limbs  ; and  the  hospital  surgeon 
of  necessity  sometimes  operates  in  a less  severe  form  of  these  injuries 
thorn  the  country  surgeon,  and  hence  ought  to  he  more  successful,  hut 
is  not. 

The  surgeon  to  our  large  hospitals  is  not  with  this,  any  more 
than  with  other  complications,  so  successful  as  the  country  surgeon. 
He  loses  48  per  cent  of  his  amputations  for  injuries;  while  the 
country  surgeon  loses  only  1 1 per  cent,  or  four  times  less.  Yet  the 
country  surgeon  operates,  on  the  whole,  on  a more  formidable  and 
dangerous,  and  hence  less  favourable,  class  of  cases  ; for  he  can  save 
from  amputation,  and  conserve  and  cure  without  the  dismemberment 
of  the  patient,  various  less  severe  types  of  compound  fracture,  which, 
when  removed  to  hospital,  require  to  be  cut  off.  On  this  point  I 
have  elsewhere  adduced  the  strongest  evidence  from  various  author- 
ities, to  the  effect  that  severe  compound  fractures  often  do  perfectly 
w^ell  in  the  healthy  isolated  country  cottage  which  would  require  to 
be  inevitably  amputated  in  the  wards  of  a large  hospital.'  “ In 
compound  fractures,”  observes,  for  example.  Dr.  Eedwood  of  Khyra- 
ney,  “ Avhere  there  is  tissue  left  that  will  continue  the  circulation 
below  the  seat  of  injury,  we  save  the  limb.  Assistants  fresh  from 
hospitals  are  often  astonished  at  what  is  attempted  and  effected  in 
this  way.”  Mr.  Davidson  of  Seaton-Delaval,  who  has  had  immense 
experience  in  these  cases,  has  related  to  me  the  same  fact  in  nearly 
the  same  words,  and  told  me  how  often  his  assistants  (seven  in 
number)  are  astonished  at  the  results  in  these  cases,  as  compared 
with  what  they  had  seen  in  hospital  practice.  One  of  the  most 
thoughtful  and  accomplished  hospital  surgeons  of  England,  Dr. 
Heath  of  Newcastle,  who  sees  much  hospital  as  well  as  much 
country  practice  in  these  cases,  lately  stated  to  me  in  the  strongest 
terms  the  same  observation  as  the  result  of  his  very  extensive 
experience. 

There  is  another  kind  of  evidence  in  proof  of  the  greater  severity 
of  the  cases  of  injury  amputated  by  the  country  surgeon — namely, 
^ See  the  evidence  on  this  point  of  various  observers  in  Chapter  II. 


PROPOSITIONS  ON. 


375 


the  greater  number  of  deaths  by  mere  “ shock”  in  the  practice  of 
the  country  surgeon.  For  we  may  lay  this  down  as  another 

Proposition  XV. — In  consequence  of  the  relative  severity  of  the  cases 
of  injury  treated  by  amputation  in  the  country,  more  die  of  simple 
shock  in  country  practice  than  in  large  hospital  practice. 

In  the  returns  of  deaths  from  the  country  amputations,  as  many 
as  36  per  cent  are  returned  as  having  died  of  shock ; or  63  cases  in 
all.  Of  these  63  cases,  in  56  the  deaths  from  shock  were  after 
amputations  for  the  results  of  injury,  and  in  7 after  amputations  for 
the  results  of  disease. 

Out  of  41  deaths  in  149  amputations  at  St.  George’s  Hospital 
recorded  by  Mr.  Holmes  only  two  are  reported  as  having  died  of 
“ shock.”  A larger  proportion  will  probably  be  found  to  die  from 
this  cause  at  other  metropolitan  and  large  hospitals.  But  I may 
recur  to  this  subject  under  Proposition  XVII. 

It  has  been  occasionally  averred  that  our  large  hospitals  are 
likely  to  receive  the  worst  forms  of  injury  requiring  amputation ; 
and  it  may  be  so  in  some  districts  and  localities,  but  certainly  not 
in  all,  for  the  preceding  remarks  so  far  prove  the  contrary.  Some 
time  ago  I received  from  Dr.  Bellenden  of  Dudley  a return  of  limb- 
amputations  in. private  practice,  too  late  to  be  included  in  the 
general  table  in  Chapter  I.  He  reports  to  me  22  amputations  with- 
out a death,  13  of  them  being  amputations  of  the  thigh;  and  he 
adds  a remark,  showing  that  in  some  places  cases  of  minor  injuries 
are  forwarded  to  hospital,  and  the  graver  accidents  retained  at  home, 
the  men  being  too  damaged  to  be  forwarded  to  a distance.  “ Most 
of  the  removable  accidents,”  writes  Dr.  Bellenden,  “in  our  collieries 
and  works  are  taken  to  the  South  Staffordshire  Hospital,  the  worst 
cases  are  left  behind.”  “ I do  not  hesitate,”  he  adds,  “ in  asserting, 
that  cases  sent  to  the  hospital  are  much  more  lingering  than  similar 
cases  treated  in  their  own  homes.” 

Formerly  it  was  sometimes  supposed  and  argued  that  hospital 
amputations  were  so  much  more  dangerous  and  fatal  than  country 
amputations,  in  consequence  of  the  hospital  cases  being  more  severe, 
and  the  patients  dying  from  the  mere  effects  of  shock.  These 
observations  rebut  entirely  this  kind  of  vague  reasoning.  Nay, 
more : we  have  seen  under  Proposition  VH.  that  the  greatest 
amount  of  proportionate  difference  between  the  death-rate  of  limb- 
amputations  in  hospital  and  in  country  practice  is  in  amputations  of 
80 


376 


HOSPITALISM  : 


the  forearm,  forearm-amputations  being  .twenty  or  thirty  times  more 
fatal  in  large  hospitals  than  in  private  country  practice;  and  yet  no  one 
could  argue  that  this  vast  difference  was  ascribable  either  to  shock 
before  or  shock  after  this,  the  least  of  the  four  major  amputations 
of  the  limbs. 

Proposition  XVI. — Amputations  of  the  thigh  for  disease  are  more 

common  in  infirmary  than  in  country  practice,  hut  are  three  times 

more  dangerous  in  hospital  than  in  rural  practice. 

Tubercular  disease  of  the  joints  and  bones  is  by  far  the  most 
common  cause  of  pathological  amputations  of  the  thigh,  and,  to  a 
less  degree,  of  the  leg  also.  “ In  common  practice,”  long  ago 
observed  Sir  Charles  Bell,^  “ amputation  is  performed,  ninety  times 
in  a hundred,  for  ulcer  with  carious  bone,  and  for  white  swelling  of 
the  joints.”  These,  like  other  cases  of  scrofulous  disease,  are  far 
more  likely  to  be  cured — where  a cure  is  possible — when  the 
patients  are  under  salutary  country  influences  than  when  shut  up  in 
the  wards  of  a large  city  hospital.  But  they  form  a class  of  cases 
which  naturally  gravitates  towards  large  hospitals.  The  patients 
are  invalided,  crippled,  and  bed-ridden  for  weeks  and  months,  and 
sometimes  for  years.  If  belonging  to  the  poorer  classes,  they  often 
thus  exhaust  betimes  their  own  little  means,  the  means  of  their 
relatives,  friends,  and  neighbours  ; and  perhaps  get  aid  begrudingly 
from  official  sources.  The  prospect  of  a possible  cure,  of  more 
generous  diet  and  wine,  and  of  more  absolute  rest,  draws  them 
naturally  to  a city  hospital ; and  the  country  medical  practitioner 
has  no  objection,  but  the  reverse,  as  it  rids  him  of  much  responsi- 
bility and  trouble  in  such  an  unfavourable  set  of  cases.  If  the  case 
is  not  a fit  one  for  resection  of  the  joint,  or  removal  of  the  diseased 
bones,  amputation  as  a matter  of  necessity  is  ultimately  and  pro- 
perly had  recourse  to.  In  the  2098  country,  and  2089  hospital, 
amputations  which  I have  already  published,  there  ivas  in  each  set 
a nearly  equal  number  of  primary  or  traumatic  amputations  of  the 
thigh — viz.  313  in  the  country  lists,  and  304  in  the  hospital  lists. 
But  of  pathological  or  diseased  amputations  there  were  only  356  am- 
putations’of  the  thigh  for  disease  in  the  country  returns,  and  as 
many  as  631  in  the  city  hospital  returns. 

AVhen  the  operation,  however,  of  amputation  of  the  thigh,  for 
disease  was  practised  upon  the  patients  in  the  country  in  their 
isolated  homes,  the  success  of  the  operation  was  far  greater  than 
1 See  his  System  of  Operative  Surgery,  vol.  i.  p.  366. 


PROPOSITIONS  ON. 


377 


when  they  were  immured  within  the  walls  of  a large  hospital.  For, 
when  operated  upon  in  their  own  houses  only  12  in  the  100  died  ; 
whilst,  when  operated  upon  in  hospitals,  as  many  as  37  in  the  100 
died  ; or,  in  other  words,  the  thigh-amputations  for  disease  proved 
three  times  more  deadly  in  city  hospital  wards  than  in  country 
private  dwellings. 

Mr.  Holmes,  as  we  have  seen  under  some  previous  propositions, 
confuses  the  two  questions  of  the  rates  of  death  after  amputation, 
and  the  causes  of  death  after  amputation.  On,  however,  this  latter 
and  favourite  subject  of  his  I have  published  some  returns  as  to  the 
2000  odd  country  amputation  cases,  which  are,  I think,  of  no  small 
value  ; for  they  go  to  prove,  as  another  proposition,  this  fact,  viz. — 

Proposition  XVII. — The  causes  of  death  after  limb-amputations  differ 
in  some  important  points  in  large  hospitals  and  in  private  country 
practice. 

Among  the  2098  country  amputations  reported  to  me,  227 
died.  The  causes  of  death  have  been  returned  to  me  in  173  out  of 
these  227  cases,  giving  in  every  probability  a fair  average  of  the 
w^hole.  Of  these  173  cases,  63  are  stated  to  have  died  of  shock;  8 
of  pyaemia;  28  of  exhaustion;  18  of  gangrene  of  the  stump  ; 9 of 
secondary  hemorrhage ; 11  of  tetanus;  13  or. more  of  internal  in- 
juries ; 23  of  miscellaneous  causes,  as  pneumonia,  phthisis,  diarrhoea, 
convulsions,  anasarca,  etc. 

Contrast  this  with  the  causes  of  death  in  a metropolitan  hospital 
— such,  for  example,  as  the  one  to  which  Mr.  Holmes  belongs — 
viz.  St.  George’s.  Apparently  from  faith  in  the  fact  that  amputa- 
tions form  the  best  test  of  the  salubrity  and  status  of  an  hospital, 
an  “amputation  book”  was  begun  in  St.  George’s  in  1852,  and, 
with  slight  exceptions,  has  been  continued  downwards  to  the  present 
time.  In  the  Medical  Times  for  6th  April,  1861,  Mr.  Holmes  has 
published  the  results  of  the  first  149  cases  entered  in  this  amputa- 
tion book.^  Of  these  149  operations  41  proved  fatal.  The  causes 
of  death  are  entered  by  him  in  percentages.  The  following  table 
shows  the  differences  between  these  41  cases  and  their  causes  of 
death  after  amputation  in  a metropolitan  hospital,  and  173  cases 
and  their  causes  of  death  in  private  country  practice. 

^ In  the  first  volume  of  St.  George's  Hosintal  Reports  Mr.  Holmes  has  more 
lately  published  an  account  of  the  first  300  cases  in  this  “ amputation  book  ; ” 
but  the  account  of  the  deaths  is  so  involved,  that  I have,  for  the  sake  of  certainty, 
followed  the  more  simple  account  in  the  Medical  Times. 


378 


HOSPITALISM  : 


Table  XXI. — Percentage  of  Different  Causes  of  Death  after 


Amputation. 

In  41  fatal  cases  in  St. 

In  173  fatal  cases  in 

George 

’s  Hospital. 

country  practice. 

Shock ^ .... 

5 per  cent 

36-4 

per  cent. 

Pyaemia  .... 

58-5  „ . 

4-6 

Exhaustion,  without  hemor- . _ . . _ . 

rhage  ...  . j 

17  „ . 

16-2 

>» 

Exhaustion,  with  secondary  'j 
hemorrhage  . . . j 

9.7  „ . 

5-2 

» 

Visceral  diseases 

9-7  „ . 

12.7 

Diffuse  inflammation  and  gan-  "j 

2-4  „ . 

10-4 

grene  . ...  ) 

Tetanus  .... 

...  „ 

6-3 

Other  injuries  . 

2*4  „ . 

7-5 

I have  interpolated  this  proposition  respecting  the  causes  of 
death  in  a metropolitan  hospital  like  St.  George’s  and  in  country- 
practice,  for  the  purpose  of  adding  the  following  as  another  and  still 
more  important  proposition — namely, 

Proposition  XVIII. — The  causes  of  death  which  Mr.  Holmes  points 
out  as  the  reasons  for  the  greater  mortality  of  amputations  in  the 
Parisian  as  compared  with  the  London  hospitals,  are  the  same  causes 
that  produce  the  greater  mortality  of  amputations  in  our  large 
IJritish  hospitals  as  compared  with  country  practice. 

After  describing  the  different  death-rates  in  Parisian  and  in 
London  hospitals,  and  showing  those  of  Paris  to  be  “ evidently 
enormous  ” as  compared  with  those  of  London,  Mr.  Holmes  states 
that  the  differences  are  certainly  not  explicable  by  differences 
either  in  the  constitution  of  those  operated  upon  in  the  French 
hospitals,  or  in  the  nature  of  the  injuries  or  diseases  for  which  they 
. are  admitted  ; and  then  adds,  “ Indeed  it  is  allowed  that  pyaemia 
and  such  diseases  are  in  great  measure  the  causes  of  these  alarming 
results”  (p.  563).  Elsewhere,  after  showing,  by  instances,  that  in 
English  hospitals  the  “ intensity  of  the  traumatic  atmosphere  is 
competent  to  engender  erysipelas  and  pyaemia,”  Mr.  Holmes 
adds — “The  above  teachings  are  entirely  in  accordance  with  the 

^ Mr.  Holmes  gives  the  deaths  from  shock  iii  one  table  ; but  not  in  his  final 
table  of  percentages.  Hence  this  percentage  column  appears  so  far  in  excess  in 
its  numbers. 


PROPOSITIONS  ON. 


379 


opinions  of  those  who  maintain  that  the  prevalence  of  erysipelas, 
pyaemia,  and  the  like,  in  the  Paris  hospitals,  is  due  to  hygienic 
defects.  It  is  known  that  some  French  authorities,  while  admitting 
the  fact  of  the  greater  prevalence  of  these  affections  in  their 
hospitals  than  in  the  hospitals  of  England,  maintain  that  tlie 
difference  is  chiefly  due  to  constitutional  differences  between 
Frenchmen  and  Englishmen.  If  it  could  be  clearly  shown  that 
the  relatively  greater  number  of  deaths  among  Frenchmen  after 
operations  and  injuries  was  due  to  shock,  this  view  might  possibly 
be  tenable  ; but  it  can  scarcely  be  accepted  as  the  true  one  if  the 
deaths  can  be  shown  to  be  (as  in  fact  they  are)  due  to  the  super- 
vention of  special  complications,  known  to  be  natural  corlsequences 
of  certain  defects  of  hygiene,  which  very  defects  prevail,  with 
scarcely  an  exception,  in  the  hospitals  of  Paris”  (p.  549). 

In  these  passages  we  have  laid  down  for  our  guidance  by  Mr. 
Holmes  two  pathological  i^rinciples  or  rules : — 

1st.  That  if  the  “ enormous”  Parisian  death-rate  were  the  result 
of  some  general  debility  in  the  constitutions  of  the  Parisian  hospital 
patients,  they  ought  to  present  a “ relatively  greater  number  of 
deaths  due  to  shocks  But — 

2d.  It  is  “pyaemia  and  such  diseases”  that  are,  in  great  measure, 
the  causes  of  the  enormous  mortality  of  surgical  operations  in  the 
Parisian  as  compared  with  the  London  hospitals. 

Exactly,  however,  in  the  same  way,  we  have  equal  and  indeed 
still  stronger  evidence  to  the  effect  that  the  “ enormous  ” death-rate 
after  limb-amputations  in  large  British  hospital  practice,  as  com- 
pared with  country  practice,  is  not  owing  to  constitutional  debility 
and  consequent  greater  number  of  deaths  by  shock  in  the  hospital 
patients  ; but,  on  the  contrary,  is  the  result  of  pyaemia  and  those 
congener  affections  which  are  the  “ natural  consequences”  of 
defective  hospital  hygiene. 

I depend  for  the  present  upon  the  proof  of  all  this  as  furnished 
in  the  writings  of  Mr.  Holmes  himself.  Let  us  glance  first  at  the 
question  of  the  evidence  of  the  amount  of — 

1.  Death  by  Shock. — Under  Proposition  XVII.  we  have  seen 
evidence  regarding  the  relative  frequency  of  death  by  shock  after 
amputations  in  St.  George’s  Hospital  and  in  country  practice  as 
amounting  to  this  : — 


In  country  practice  36  in  100  die  of  shock. 
In  hospital  „ 5 in  100  „ 


380 


HOSPITALISM  : 


Hence,  therefore,  as  we  cannot  account  for  the  “enormous”  differ- 
ences between  the  death-rate  in  Parisian  as  compared  with  English 
hospitals  by  finding  the  Parisians  less  able  to  bear  amputation,  as 
tested  by  more  of  them  dying  of  shock,  so  we  cannot  account  either 
for  the  “ enormous  ” differences  between  the  death-rate  in  large 
British  hospital  practice  as  compared  with  country  practice  by 
finding  the  hospital  patients  dying  in  comparatively  greater  propor- 
tion by  shock  ; for  the  very  reverse  is  the  fact. 

2.  Death  hy  Pijcemia,  etc. — According  to  Mr.  Holmes  and  most 
modern  surgical  pathologists,  pyaemia  or  surgical  fever  is  the  most 
common  cause  of  death  in  hospitals  after  amputation  and  other 
operations  (see  the  quotations  under  Proposition  VIH.) ; and  in  the 
passage  cited  one  or  two  paragraphs  back,  Mr.  Holmes  expresses 
the  general  opinion  that  the  high  mortality  of  the  amputations  in 
the  Parisian  hospitals  is  due  to  this  pathological  cause.  Pyaemia  is 
shown  to  be  the  cause  of  death  in  more  than  a half  of  those  that  die 
in  St.  George’s  Hospital.  (See  Table  XXL)  Mr.  Bryant,  the 
well-known  surgeon  of  Guy’s  Hospital,  in  an  excellent  paper  “ On 
the  Causes  of  Death  after  Amputation,”  came  to  the  conclusion 
that,  in  the  hospital  to  which  he  is  attached,  “ pyaemia  is  the  cause 
of  death  in  42  per  cent  of  all  fatal  cases  of  amputation  and  Mr, 
Holmes  criticises  this  as  probably  too  small.  Perhaps  we  may 
justly  hold,  as  a mean  between  the  two,  50  per  cent  of  the  deaths 
after  amputation  in  our  large  hospitals  as  the  result  of  pyaemia.^ 

To  what  extent  is  this  fatal  complication,  pyaemia,  the  cause  of 
death  in  country  amputations  ? Pyaemia  is  returned  as  the  cause  of 
death  in  8 out  of  173  fatal  cases  in  which  the  various  pathological 
causes  of  death  are  reported  to  me.^  Hence  we  have  this  general 
result  from  those  observations,  that 

In  fatal  country  amputations,  5 in  100  die  of  pyaemia. 

In  fatal  hospital  amputations,  50  in  100  die  of  pyaemia. 

If,  then,  pyaemia  and  its  analogous  diseases  form,  by  their 
relative  prevalence,  as  Mr.  Holmes  correctly  maintains,  the  great 
cause  of  the  “ enormous  ” difference  between  the  death-rates  after 
amputation  in  the  hospitals  of  Paris  and  the  death-rates  after 

^ McMco-CMrurgical  Transactions,  vol.  xlii.  p.  87. 

2 In  a table  kindly  drawn  np  for  me  by  Mr.  M'Dougal  of  the  causes  of  death 
in  72  fatal  limb-amputations  in  the  Edinburgh  Infirmary  from  October  1865  to 
October  1868,  34,  or  nearly  a half,  died  of  pyaemia,  and  11  of  shock. 

* See  Chapter  II. 


PROPOSITIONS  ON. 


381 


amputation  in  the  hospitals  of  London,  it  forms  also,  with  its  con- 
geners, one  of  the  great,  or  indeed  the  greatest  cause  of  the 
enormous  difference,  in  the  death-rates  in  England,  between  large 
hospital  practice  and  private  country  practice,  as  expressed  in  our 
present  proposition. 

The  relative  prevalence  of  this  formidable  and  fatal  complication 
within  the  walls  of  St.  George’s  Hospital,  with  three  or  four 
hundred  inmates,  and  the  district  without,  from  which  the  hospital 
chiefly  derives  its  patients,  containing  a population  of  thousands,  or 
tens  of  thousands,  is  presented  by  a statement  made  by  Mr.  Holmes 
in  one  of  his  papers  in  The  Lancet.  From  18G5  to  18G8  there 
originated  81  cases  of  pysemia  within  the  walls  of  St.  George’s 
Hospital ; while  during  the  same  period  9 cases  applied  for 
admission  from  without.  Few  facts  perhaps  could  show  more 
clearly  the  usual  hospital  origin  and  character  of  this  dreaded 
disease. 


382 


HOSPITALISM  ; 


CHAPTER  IV. 

SOME  PROPOSITIONS  ON  HOSPITALISM — {continue^. 

Why  is  Hospitalism  dangerous  to  the  Sick? — Seeing,  as  we 
have  in  the  last  proposition,  that  pysemia  and  its  allied  affections 
form  the  main  sources  of  death  in  hospital  patients  after  limb-am- 
putations, and  that  this  class  of  diseases  is,  as  stated  by  Mr.  Holmes 
and  others,  the  consequence  of  defective  hospital  hygiene,  or  the 
result  of  hospitalism,  let  us  try  briefly  to  inquire  how  the  aggrega- 
tion of  invalids  within  an  hospital  leads  to  the  frequent  production 
of  this  and  other  forms  of  surgical  fever  in  surgical  wards ; while 
they  are  relatively  so  rare  in  country  and  private  practice,  where  the 
patients  are  separate  and  isolated. 

There  exists,  I think,  evidence  on  this  question,  tending  to  show 
that  the  constitution  of  the  surgical  patient  in  surgical  wards  is  liable 
to  be  endangered  sometimes  by  the  influence  of  morbific  contagious 
materials  from  the  bodies  of  the  other  inmates,  though  the  blood- 
poisoning  which  leads  on  to  pysemia  is  generally  produced  by  the 
inhalation  of  organic  and  other  materials  which  usually  exist  in  the 
air  of  hospital  wards,  but  which  are  not  contagious.  Besides,  the 
aggregation,  or  compression  into  a limited  dwelling  place  like  an 
hospital  ward,  of  men  even  in  a state  of  relative  bodily  and  physical 
health,  leads  to  some  danger  by  hospitalisation,  and  renders  the 
mortality  among  them  higher  than  when  the  same  class  of  men  are 
lodged  in  separate  and  private  dwellings. 

Proposition  XIX. — Surgical  patients  in  surgical  wards  seem  sometimes 
to  have  pyaemia  or  surgical  fever  induced  by  the  accidental  inocula- 
tion of  the  morbific  secretions  formed  in  the  bodies  of  other  patients 
previously  affected. 

The  obstetric  physicians  of  Great  Britain  generally  agree,  I be- 
lieve, as  to  the  occasional  spread  of  puerperal  fever  in  this  mode  from 


rilOPOSITIONS  ON. 


383 


the  affected  to  the  healthy  by  the  unhappy  and  indirect  medium  of 
the  physician,  nurse,  etc.,  as  well  as  by  contagious  miasmata.  The 
great  liability  to  the  occurrence  of  this  dire  malady  renders  the  con- 
sideration of  the  proper  dimensions  and  construction  of  a lying-in 
hospital  not  a mere  problem  of  space  and  size,  but  of  adequate  isola- 
tion also  for  the  individual  inmates.  It  is  hence,  with  regard  to 
obstetric  hospitals,  a question  of  contagion  as  well  as  a question  of 
crowding.  Surgeons  seem,  however,  to  consider  the  production  of 
l^yjEinia  by  contagion,  direct  or  indirect,  as  far  more  rarely  a cause 
of  surgical  than  it  is  acknowledged  to  be  of  puerperal  fever.  In 
some  observations  which  I published  several  years  ago  upon  the 
various  analogies  of  puerperal  and  surgical  fever,  I suggested  the 
occasional  spread  of  the  latter  disease  by  means  of  occasional  con- 
tagion and  inoculation  (see  Edinburgh  Monthly  Journal  of  Medicine  for 
November  1850) ; but  the  matter  has  hitherto  attracted  little  atten- 
tion from  our  hospital  surgeons. 

There  are,  perhaps,  other  modes  in  which  the  blood  becomes 
more  frequently  vitiated  in  surgical  wards,  so  as  to  lead  on  to  the 
production  of  pyaemia.  For  we  may  hold  the  following  as  a more 
established  proposition  : — 

Proposition  XX. — The  air  breathed  by  patients  aggregated  in  surgical 
wards  becomes  sometimes  morbific  and  dangerous  by  its  containing 
various  inorganic  and  organic  materials,  and  by  the  inmates  mutu- 
ally vitiating  it  more  or  less  by  the  exhalations  and  excretions  from 
their  wounded,  ulcerating,  and  sick  bodies. 

In  treating  of  the  insalubrity  of  surgical  hospitals  and  wards, 
Baron  Larrey  observes : — “ The  danger  of  surgical  operations  de- 
pends upon  the  vitiation  of  the  atmosphere,  especially  during  the 
night.  The  natural  excretions  of  the  sick,  the  breath,  the  fetid 
perspirations,  the  expectorated  matter,  the  intestinal  and  urinary 
evacuations,  the  suppurations  from  wounds  and  ulcers,  and  some- 
times the  putridity  of  mortification  or  of  hospital  gangrene,  are  so 
many  sources  or  foci  of  contamination  ; without  counting  the  odours 
of  medicine,  tisanes,  and  poultices,  the  evaporation  from  liquids,  the 
emanations  from  the  soil,  from  the  oil  or  gas  used  for  illumination, 
from  the  bed-linen,  and  from  the  too  closely  situated  or  badly  con- 
structed latrines.” 

The  air  of  surgical  and  hospital  wards  contains,  according  to  later 
observations,  various  materials  additional  to  those  mentioned  by 


384 


HOSPITALISM  : 


Baron  Larrey.  “The  extent,”  observes  Mr.  Simon,  writing  in  1864, 
“ to  whicli  organic  matter  may  be  present  as  floating  dust  in  such 
atmospheres  as  that  of  an  ill-ventilated  hospital  ward  is  only  be- 
ginning to  be  recognised;”  and  he  adduces  the  evidence  of  Dr. 
Thomson  and  Mr.  Rainey  as  to  epidermic  scales  and  minute  hairs, 
vegetable  fibres  and  starch  granules,  and  living  forms,  both  animal 
and  vegetable,  vibriones  and  the  mycelia  of  fungi,  having  been  found 
floating  in  the  air  of  the  cholera  ward  of  St.  Thomas’s  Hospital. 
These  bodies,  with  bacteria,  etc.,  have  latterly  been  detected  abun- 
dantly in  the  atmosphere  of  other  hospitals  and  crowded  dwellings, 
and  especially  by  Drs.  De  Chaumont,  Frank,  Hewlett,  and  other 
medical  officers  of  the  English  army.  Pasteur,  Gratiolet,  Lemaire, 
and  others,  maintain  that  the  atmosphere  is  full  (especially  in 
localities  where,  as  in  hospitals,  the  air  is  otherwise  impure  and 
tainted)  of  living  spores  and  germs  of  various  infusoria,  etc.,  which, 
when  they  find  a proper  nidus,  lead  on  by  their  development  to  fer- 
mentations, putrefaction,  suppurations,  etc. 

Lately,  in  the  air  of  a prison,  Lemaire  detected  various  round  or 
oval  bodies  of  the  same  form  as,  in  uncleanly  persons,  exist  in  the 
sweat.  M.  Pouchet  states  that  he  has  discovered  abundance  of 
organic  debris  in  the  air ; and  Chalvet  found  in  the  wards  of  St. 
Louis  Hospital,  at  Paris — what  Revert  had  previously  found  at  the 
Lariboisi^re — namely,  floating  organic  matters  in  the  surgical  wards ; 
and  more  in  them  than  in  the  medical  wards.  The  extent  to  which 
epithelial  and  other  cells  contribute  in  forming  the  organic  matter  in 
badly-cleaned  hospitals  is  shown  by  the  dust  collected  in  the  wards 
of  St.  Louis,  this  dust  being  found  to  contain  in  one  experiment  36 
per  cent,  and  in  another  46  per  cent.  These  organic  ingredients  of 
the  hospital-dust  give  out  an  odour  of  horn  when  burnt,  and  a fetid, 
putrid  smell  when  moistened  and  allowed  to  decompose.  When 
lying  on  the  floor  of  the  ward,  this  organic  powder  can  be  readily 
lifted  by  the  passing  draughts  of  air,  and  by  the  force  of  evaporation 
of  water. 

Dangers  occasionally  seem  to  exist  in  other  directions.  “ The 
walls  and  floors  of  hospitals,”  writes  Dr.  Parkes,  “ absorb  organic 
matters,  and  retain  them  obstinately ; so  that,  in  some  cases  of  re- 
peated attacks  of  hospital  gangrene  in  a ward,  it  has  been  found 
necessary  to  destroy  even  the  whole  wall and  “the  bedding  and 

^ See  Dr.  Bristowe  and  Mr.  Holmes’s  account  of  one  of  the  wards  of  old  St. 
Thomas’s  Hospital,  where  pyremia  persisted  and  returned  in  spite  of  the  emptying 
of  the  ward,  painting  of  the  walls,  etc. — P.  593. 


PKOPOSITIONS  ON. 


385 


furniture  also  absorb  organic  substances,  and  are  a great  cause  of 
insalubrity.” 

Some  years  ago  it  was  announced  by  Eiselt  that  pus-corpuscles 
existed  in  the  air  of  a ward  at  Prague  in  which  ophthalmia  was 
prevailing;  and  Stromeyer,  Dr.  Parkes,  and  others,  hold  that  in 
erysipelas,  hospital  gangrene,  etc.,  dried  and  disintegrating  pus-cells 
and  putrefying  organic  particles  pass  into  and  float  in  the  atmo- 
sphere. All  these  various  ingredients,  when  floating  in  the  air,  are 
of  course  liable  to  be  inhaled,  and  some  of  them  absorbed  after 
inhalation,  by  the  patients  in  the  wards. 

Important  results,  both  in  a pathological  and  hygienic  point  of 
view,  will,  probably,  ere  long  result  from  the  more  elaborate  pursuit 
of  this  class  of  inquiries.  Through  the  inhalation  of  such  materials 
floating  in  the  atmosphere,  or  in  some  such  way,  in  all  probability 
“ certain  diseases,”  remarks  Dr.  Parkes,  “ are  propagated ; the  dried 
substance — as,  for  example,  the  evacuations  of  cholera  or  dysentery 
— floating  through  the  air,  and  being  finally  swallowed  or  inhaled 
into  the  lungs.  The  specific  poison  of  small-pox  derived  from  the 
skin ; of  scarlet  fever  derived  from  the  skin,  throat,  and  urine  (1) ; 
of  measles  derived  from  the  skin  and  lungs  (?),  etc.,  must  also  be 
molecular  organic  matter,  or  even  formed  corpuscles,  though  as  yet 
they  have  not  been  recognised.” 

It  is  well  known,  both  from  observation  and  experiment,  that 
when  once  any  such  ingredients  exist  in  the  atmosphere,  they  are, 
in  consequence  of  the  laws  of  the  diffusion  of  air  and  gases,  so 
swiftly  spread  as  speedily  to  travel  through  an  hospital  ward,  and 
also  into  any  adjoining  passages,  corridors,  or  staircases, — and  even 
into  the  distant  wards  or  rooms.  This  fact  might  be  variously 
illustrated  ; but  I shall  content  myself  with  citing  one  example  as 
sufficient  to  enforce  the  remark.  Some  time  ago  an  empyema,  con- 
taining very  fetid  pus,  was  opened  in  a ward  towards  the  end  of  the 
long  corridor,  or  gallery,  in  the  gigantic  hospital  at  Netley.  Tlie 
smell  from  this  putrid  pus  diffused  itself  along  the  corridor,  so  that, 
as  I am  informed  by  Dr.  Parkes,  it  was  ere  long  felt  and  complained 
of  in  rooms  or  wards  up  to  five  hundred  feet  distant  on  one  side. 
But  there  are  morbific  and  probably  organic  materials  far  more 
subtle,  inscrutable,  and  deadly  than  merely  bad  aromas  ; as  the 
contagious  and  malarial  entities  capable  of  producing  typhus  fever, 
scarlatina,  ague,  etc. 

Every  human  being  seems  to  exhale  from  his  body  an  aroma,  so 
far  individually  distinct  that  the  dog  can  trace  by  it  the  footsteps  of 


38G 


HOSPITALISM  : 


his  master.  “ More  organic  effluvia,”  to  quote  Dr.  Parkes’s  words, 
“ are  given  off  from  the  bodies  and  excretions  of  sick  men.”  * When 
two  sick  men  are  laid  down  in  the  same  room,  there  is  always  a 
chance — slight  in  many  cases  it  may  be — of  one  of  them  deleteri- 
ously  affecting  in  this  way,  by  his  exhalations,  the  bodily  state  of 
the  other.  When  a sick  or  wounded  patient  is  placed  in  a room  or 
chamber  by  himself  all  such  mischances  from  others  are  averted ; 
and  hence  the  advantages  of  perfect  isolation  of  the  sick.  The 
danger,  however,  on  the  other  hand,  no  doubt  multiplies  as  the 
number  of  patients  aggregated  together  is  increased.  In  a ward  of 
ten  patients  there  is,  cceteris  paribus,  a greater  likelihood  of  harm 
than  in  a ward  of  two,  and  that  specially  on  account  of  two  reasons. 
For,  first,  they  are  all  respiring  the  air  mutually  deteriorated  by  the 
whole  increased  number  of  sick ; but,  secondly,  and  chiefly,  there  is 
every  chance  that  among  this  increased  number  of  sick  there  may 
be  one  invalid,  if  not  more,  whose  corporeal  exhalations  infect  and 
pollute  the  air  of  the  ward — and  consequently  the  air  breathed  by 
the  other  sick  inmates  of  the  ward — in  such  a manner  or  in  such  a 
degree  as,  when  long  inspired,  to  be  specially  and  specifically 
dangerous  to  the  health  and  constitutions  of  one  or  others  of  the 
neighbouring  patients.  The  hazard  from  this  cause  necessarily  in- 
creases with  the  increased  number  of  sick  persons  in  a ward ; and 
consequently  also  in  an  hospital  under  one  roof,  and  whose  wards  all 
more  or  less  intercommunicate  by  passages,  corridors,  etc.  ; for  the 
hospital  comes  in  this  case  to  be,  as  far  as  the  intermixture  of  its 
whole  atmosphere  is  concerned,  only  one  enormous  and  gigantic 
chamber.  Suppose,  for  the  sake  of  illustration,  that  there  is  a risk 
of  danger  in  a ward  of  ten  invalids,  from  the  polluting  and  morbific 
exhalations  proceeding  from  the  diseased  body  of  one  of  the  ten, — 
then,  in  a ward,  or  series  of  communicating  wards,  containing,  say, 
fifty  patients,  we  may  very  roughly  and  conjecturally  estimate  that 
five  out  of  the  fifty  will  be  similar  sources  of  perilous  deterioration 
and  vitiation  of  the  general  atmosphere ; in  an  hospital  of  one 
hundred  beds,  there  may  be  ten  such  special  centres  ; in  an  hospital 
of  two  hundred  beds  under  one  roof,  twenty  similar  nuclei  of  infec- 
tion ; and  in  one  of  five  hundred  beds,  fifty  such  sources  of  danger 
and  disease  to  the  included  inmates.  The  effect  of  special  Autiations 
of  the  air  mutually  produced  by  different  patients  has  not,  of  course, 
it  must  be  further  observed,  necessarily  the  same  influence  upon  all. 
The  effects  of  these  and  other  etiological  poisons  vary  with  the 
^ See  his  admirable  Manual  of  Practical  Hygiene,  p,  323. 


PKOPOSITIONS  ON. 


387 


susceptibility  and  state  of  predisposition  of  tliose  avIio  are  subjected 
to  them.  An  atmosphere  full  of  typhus  poison  does  not  by  any 
means  strike  down  all  that  breathe  it.  Nor  does  exposure  to  air  full 
of  malarial  poison  produce  ague  in  all  exposed  to  it ; and  again, 
occasionally,  when  it  causes  ague  in  some,  it  creates — according  to 
their  condition  of  predisposition — dysentery  in  some,  sickness  and 
headache  in  others,  etc.  What  special  varieties  or  forms  of  hospital 
poison  produce,  when  inhaled,  py£emia,  has  not  yet  been  fully  estab- 
lished by  surgical  science ; nor  are  we  at  all  aware  of  the  special 
predispositions  in  patients  which  enable  these  poisons  to  develop  the 
disease.  The  inquiry  is  one  full  of  moment,  both  in  itself,  and  in 
reference  to  the  occasional  though  far  rarer  appearance  of  pyjemia  in 
private  as  well  as  in  hospital  practice. 

Effects  of  Hospitalism  on  Healthy  Men. — In  hospitalising 
men,  or  in  aggregating  them  into  well-filled  rooms,  wards,  hospitals, 
and  the  like,  we  decrease  their  health-rate  and  increase  their  death- 
rate,  even  though  the  men  thus  hospitalised  are  comparatively  in  a 
state  of  good  corporeal  or  physical  health.  I allude  to  the  matter 
as  showing  that,  in  despite  of  some  of  the  special  evil  influences  of 
hospitals  above  adduced,  the  mere  aggregation  of  men  together  in 
hospital  and  hospital-like  establishments  is  attended  with  deleterious 
effects  to  health  and  life. 

This  circumstance  has  been  more  than  once  challenged  in  the 
pages  of  the  Lancet  during  the  course  of  the  present  year.  But  of 
its  truth  there  cannot,  I believe,  be  any  reasonable  doubt.  As 
shown  by  Dr.  Farr  of  London,  Dr.  Duncan  of  Liverpool,  and  Dr. 
Gairdner  of  Glasgow,  the  average  mortality  of  our  country  and  town 
districts,  of  our  cities  and  their  more  crowded  districts,  increases 
with  marked  regularity  according  to  the  density  of  the  inhabiting 
population.  AVhen  men  are  in  numbers  aggregated  or  compressed 
into  rooms,  or  wards,  or  hospitals,  the  same  law,  in  a marked 
measure,  overrules  the  result.  For  example,  when  soldiers — men  in 
the  prime  of  life,  and  selected  for  their  healthy  constitutions — are 
shut  up  in  crowded  barracks,  they  begin  to  suffer  and  die  in  numliers 
disproportionate  to  the  civil  population — chiefly  from  phthisis  and 
typhoid  in  this  country,  and  from  fever,  cholera,  and  dysentery  in 
India.  The  different  Government  commissions  which  have  made 
inquiries  into  the  health  of  the  British  troops  in  barracks  leave  no 
doubt  on  this  point  as  one  cause  of  the  otherwise  unaccountable 
mortality  in  our  army.  In  treating  of  the  subject  of  barracks.  Pro- 


388 


HOSPITALISM  : 


fessor  Parkes  observes  (p.  304)  : “At  all  times  the  greatest  care  is 
necessary  to  counteract  the  injurious  effects  of  compressing  a num- 
ber of  persons  into  a restricted  space.  In  the  case  of  soldiers  the 
compression  has  been  extreme.  . . No  expense,”  he  adds,  “ has 

of  late  years  been  spared,  but  yet  the  fact  remains  that  the  very 
habitations  erected  for  their  shelter  and  comfort  have  proved  to  the 
soldiers  a source  of  suffering  and  death.”  ^ 

From  these  and  similar  data  it  might  be  reasonably  argued  and 
inferred  that  hospitalisation,  or  the  compression  of  a number  of  persons, 
even  in  health,  within  a given  house,  dwelling,  or  ward,  would  be, 
in  itself,  more  or  less  prejudicial  to  their  health  and  life.  But  there 
is  one  piece  of  evidence  on  the  question,  more  precise  perhaps  than 
the  preceding,  and  which  I may  throw  into  the  form  of  another 
proposition. 


Proposition  XXI. — The  residence  in  hospital  tvards  of  men  in  a state 
of  relative  bodily  health  is  attended  ivith  a loss  of  life  markedly 
greater  than  when  the  same  class  of  men  are  not  thus  hospitalised, 
hut  allowed  to  reside  in  private  cottages  and  dwellings. 

The  evidence  in  proof  of  this  statement  is  as  follows : — The 
Board  of  the  Commissioners  in  Lunacy  for  Scotland  have  for  some 
years  past  allowed  pauper  chronic  lunatics,  chie%  dements  and 
idiots,  who  were  mentally  incurable,  and  beyond  all  hope  of  treat- 
ment from  detention  in  a lunatic  asylum,  to  be,  for  the  sake  of 
economy  and  other  reasons,  removed  from  asylums,  and  lodged  either 
— 1,  in  lunatic  wards  attached  to  poor-houses  ; or  2,  in  the  houses 
of  peasants  and  others,  with  whom  they  are  boarded,  usually  at  a 
small  expense.  Above  1600  are  thus  resident  in  private  dwellings, 
and  above  500  in  the  lunatic  wards  of  poor-houses  in  Scotland. 
These  two  classes  of  incurable  lunatics  are,  I am  informed,  similar 
in  all  essential  points,  as  far  as  a comparison  of  their  health-rates 
and  death-rates  is  concerned.  Of  the  chronic  lunatics  resident  in 
the  wards  of  poor-houses,  8 ’5  per  cent  died  annually,  on  an  average, 
from  the  years  1861  to  1867  inclusive.  Of  the  chronic  lunatics 

^ In  the  case  of  cavalry  horses,  where  the  question  is  more  simple  than  in  the 
case  of  soldiers,  in  consequence  of  the  “absolute  similarity,  in  different  places,  of 
their  food,  water,  exercise,  and  treatment,”  the  effect  on  health  and  life  in  these 
animals  from  diminution  of  numbers  in  the  stables,  and  increased  ventilation  and 
cleanliness,  has  j)roved  very  striking.  See  Dr.  Parkes’s  Treatise,  p.  84.  “ In 

cowhouses  and  kennels,”  he  adds,  “similar  facts  are  well  known;  disease  and 
health  are  in  the  direct  proportion  of  foul  and  pure  air.” 


PROPOSITIONS  ON. 


389 


resident  in  private  dwellings  there  died  annually,  on  an  average 
during  these  same  seven  years,  5*6  per  cent.  In  other  words — 

In  private  dwellings,  56  in  1000  die  annually. 

In  lunatic  wards,  86  in  1000  die  annually. 

The  mortality  among  these  pauper  patients  in  private  dwellings 
is  thus  seen  to  he  much  less  than  among  patients  in  establishments. 
Yet  the  latter,  or  those  lodged  in  the  parochial  asylums  of  poor- 
houses,  and  among  whom  the  greater  yearly  mortality  steadily  occurs, 
are  more  carefully  tended  than  the  former,  because  all  the  rules  for 
their  management  are  under  more  immediate  official  control.  Care- 
ful rules  have  been  laid  down  in  order  to  ensure  their  comfort, 
cleanliness,  good  feeding,  and  proper  clothing.  They  are,  however, 
hospitalised;  whilst  the  1600  amongst  whom  the  lesser  yearly 
mortality  occurs  are  not  hospitalised,  but  are  boarded  out  in  the 
families  of  the  peasantry  and  the  poor,  and  are  scattered  over  various 
districts  of  the  country.  In  speaking  of  the  respective  treatment  of 
these  hospitalised  and  unhospitalised  lunatics,  and  of  the  marked 
difference  of  mortality  between  the  two  classes,  the  Commissioners 
in  Lunacy  observe : “We  can  offer  no  explanation  of  this  fact  be- 
yond the  conjecture  that  the  ^manner  of  living  in  private  dwellings, 
involving,  as  a rule,  greater  freedom  and  greater  variety,  and  the 
respiration  of  an  atmosphere  less  loaded  with  animal  exhalations, 
more  than  counterbalances  the  advantages  which  better  diet,  better 
clothing,  better  bedding,  better  housing,  and  greater  cleanliness, 
might  be  supposed  to  convey  ” to  the  lunatics  lodged  in  parochial 
asylums,  as  compared  with  those  permitted  to  live  in  private 
dwellings 


390 


HOSPITALISM. 


CHAPTER  y. 

STATISTICS  OF  3077  PROVINCIAL  HOSPITAL  AMPUTATIONS. 

1.  Mortality  from  Limb- Amputations  in  the  Provincial 
Hospitals  of  Great  Britain. 

With  the  view  of  following  out  these  inquiries  as  to  the  death-rate 
of  limb-amputations  under  different  conditions,  I have  tried  to  collect 
statistics  on  the  subject  from  the  Provincial  Hospitals  of  Great 
Britain.  For  it  seemed  important  in  relation  to  some  points  in  the 
investigation  to  be  able  to  contrast  the  results  of  amputations  in  our 
more  limited  provincial  hospitals  with  the  results  of  the  same  opera- 
tions in  our  large  and  metropolitan  hospitals  on  the  one  hand,  and 
with  their  results  in  private  country  practice  on  the  other  hand. 
Besides,  the  inquiry  promised  to  offer  the  most  satisfactory  kind  of 
solution  that  could  be  obtained  to  the  question  as  to  the  size  of 
hospitals  influencing  or  not,  as  a general  law,  their  degree  of  salubrity 
or  their  degree  of  mortality. 

The  following  was  the  form  of  schedule  sent  out  to  the  different 
provincial  hospitals  of  Great  Britain,  with  the  hope  of  procuring  a 
return  of  the  cases  in  which  the  four  major  amputations  of  the  limbs 
had  been  performed  in  them  in  the  continuity  of  the  bones  : — 


“ Results  of  the  Four  Amputations  of  the  Thigh,  Leg,  Arm,  and 
Forearm,  in  the  Hospital  from  1862  to 
{Amj[)utations  through  the  Joints  are  not  to  he  included') 


Year. 

FOR  INJURY. 

FOR  DISEASE.  ! 

Thigh. 

Leg. 

Arm. 

Forearm. 

j Thigh. 

Leg. 

Arm. 

Forearm. 

No.  of 
Cases. 

Deaths. 

No.  of 
Cases. 

Deaths. 

No.  of 
Cases. 

Deaths. 

1 No.  of 

1 Cases. 

j Deaths. 

No.  of 
Cases. 

Deaths.  | 

No.  of 
Cases. 

Deaths. 

No.  of 
Cases. 

Deaths.  | 

Vh  . 

® s 

o S? 

Deaths. 

18 

18 

18 

18 

18 

18 

18 

1 

1 

1 

1 

Total  . 

1 

Signature, 
Pkcsidence, 
Date, 


Remarks. 


PROVINCIAL  HOSPITAL  AMPUTATIONS. 


391 


I asked  only  for  the  cases  from  18G2  onwards,  partly  because  I 
was  desirous  of  procuring  the  latest  returns  ; and  partly  because 
many  of  the  returns  from  these  hospitals  had  been  already  published 
up  to  that  year,  or  even  inclusive  of  it,  in  the  elaborate  official  re- 
ports drawn  up  by  Dr.  Bristowe  and  Mr.  Holmes  for  the  Medical 
Officer  of  the  Privy  Council.^  One  or  two  hospitals  furnished  me 
with  returns  from  an  earlier  year,  which  I have,  of  course,  not 
hesitated  to  include. 

In  consequence  of  the  schedules  issued,  I have,  up  to  the  time  of 
tabulating  and  calculating  all  the  data,  obtained  returns  of  the 
results  of  amputation  of  the  limbs  from  seventy-four  provincial 
hospitals  in  Great  Britain.  From  the  remainder  of  these  hospitals 
I have  failed  in  procuring  the  necessary  data.  In  some  no  register 
of  the  results  of  operations  is  kept. 

The  total  number  of  cases  of  limb-amputation  reported  from  those 
seventy-four  British  hospitals  amounts  to  3077. 

The  seventy-four  hospitals  vary  much  in  size.  In  the  tables 
which  follow,  I have  arranged  them  and  their  results  in  accordance 
with  their  individual  extent ; or,  in  other  words,  in  accordance  with 
the  number  of  beds  which  they  each  contain.  For  this  purpose,  I 
laid  down  the  following  four  divisions  or  series,  and  arranged  the 
hospitals  subsequently  under  their  respective  heads,  viz. — 

1.  Hospitals  with  2o  beds  and  under; 

2.  Hospitals  with  26  to  100  beds  ; 

3.  Hospitals  with  101  to  200  beds  ; 

4.  Hospitals  with  201  to  300  beds. 

The  only  hospitals  in  Great  Britain  which  at  present  contain  a 
larger  number  of  beds  are  the  Eoyal  Infirmaries  of  Edinburgh  and 
Glasgow,  and  the  four  Metropolitan  Hospitals  of  St.  Bartholomew’s, 
St.  George’s,  Guy’s,  and  the  London  Hospital  in  Whitechapel,  which 
can  each  accommodate  from  300  to  600  patients  or  more.  I have 
already,  in  Chapter  II.  8,  given  at  length  the  annual  amputation 
statistics  for  some  years  back  of  these  several  hospitals.  In  adduc- 
ing the  statistics  of  the  provincial  hospitals,  I shall  begin  with  those 
of  the  largest  size,  and  proceed  from  thence  downwards  in  the 
series.  In  doing  so  I shall  collect  together  into  separate  tables  all 
the  amputation  returns  furnished  to  me  pertaining  to  each  series 
individually ; and  use  for  this  purpose  the  general  sums  of  all  the 

^ See  the  Sixth  Annual  Report  of  the  Medical  Officer  of  the  Privy  Council: 
London,  1864. 


81 


392 


HOSPITALISM. 


amputations  for  all  the  years  which  I have  received  from  each 
hospital.  It  would  take  up  unnecessary  space  to  print  all  'the 
returns  for  all  the  included  years  of  each  provincial  hospital — as  I 
have  already  done  of  the  six  largest  city  or  metropolitan  hospitals 
above  referred  to.  Besides,  the  statistical  data  furnished  by  the 
provincial  hospitals  individually  are  usually  too  small  by  themselves 
for  statistical  conclusions  ; but  they  become  adequate  for  this  purpose 
when  collated  and  calculated  together  in  sufficient  masses. 

FIRST  SERIES. 

Provincial  Hospitals  with  201  to  300  Beds. 

There  are  seven  hospitals  only  included  under  this  head  : the 
largest  of  the  seven,  the  Royal  Infirmary  of  Liverpool,  containing 
270  beds,  and  the  smallest,  the  General  Hospital  of  Birminghaih, 
containing  223  beds.  One  of  the  seven  hospitals,  the  Margate 
Royal  Sea-bathing  Infirmary,  is  (to  quote  the  words  of  my  friend 
Dr.  Rowe,  in  sending  me  the  return  of  the  operations)  “ special  in 
its  character ; casualties  as  a rule  are  not  admitted,  but  are  sent  to 
the  Canterbury  Hospital.  Hence  the  entire  absence  in  the  report  of 
operations  for  injury.” 


PROVINCIAL  HOSPITAL  AMPUTATIONS. 


393 


Table  XXII. — Results  of  the  four  Amputations  of  the  Thigh,  Leg, 
Arm,  and  Forearm,  in  Seven  British  Hospitals  containing  from 
201  TO  300  Beds. 


FOR  injury. 

FOR  disease..  1 

Thif^h. 

Leg. 

Ann. 

Fore- 

Thicli. 

Lei 

Arm. 

Fore- 

Name of  Hospital. 

Years. 

arm. 

o* 

arm. 

rr 

rr 

(A 

rt 

Ui 

s 

(/i 

rt 

Vi 

s 

Sj 

X 

K 

c3 

O 

c 

6 

o 

Q 

o 

6 

6 

6 

O 

1 

Liverpool  Infir- 

mary . . 

270 

1862-8 

2216 

24 

10 

15 

4 

11 

1 

54 

18 

62 

7 

7 

3 

18 

0 

2 

Dundee  Infiriny, 

260 

1861-8 

8 

4 

9 

6 

3213 

18 

1 

5 

2 

4 

4 

4 

2 

1 

0 

3 

Newcastle  „ 

250 

1866-8 

12 

i ^ 

15 

8 

13 

8 

8 

1 

8 

2 

2 

0 

1 

0 

0 

0 

4 

Margate  Royal 

Seabathing  In- 

i 

fiinary  . . 

250 

1864-9 

0 

0 

0 

0 

0 

0 

0 

0 

23 

7 

19 

0 

5 

0 

2 

0 

5 

Bristol  Infirmary 

242 

1862-8 

5 

3 

13 

9 

8 

1 

5 

1 i 

i 32 

5 

20 

1 

2 

1 

4 

0 

6 

Aberdeen  ,, 

229 

1860-8 

15 

10 

10 

3 

10 

0 

5 

0 

41 

9 

21 

4 

3 

1 

7 

1 

7 

Birniiiighani  ) 

223 

{ 1862-4 

19 

9 

39 

20 

33 

8 

18 

4 

54 

16 

23 

4 

5 

0 

9 

2 

Gen.  Hospl.  | 

( 1866-8 

Total  . 

81 

48 

no 

49 

llli34 

65 

8 

217 

59 

151 

20 

27 

7 

41 

3 

Mortality  per  cent 

59-2 

44-5 

30*6 

12-3 

27-1 

13-2 

25-9 

nJ 

Or  proportionally  1 in  . 

1-7 

2-2 

3-2 

81 

3-6 

7‘ 

5 

3-8 

13-6  1 

Total  number  of  cases,  803  ; of  deaths,  228  ; or  1 in  every  3 5, 
or  28  3 in  100,  died. 


Total  number  of  amputations  for  injury,  367  ; of  deaths,  139  ; 
or  1 in  2*6,  or  37'8  in  100,  died. 

Total  number  of  amputations  for  disease,  436  ; of  deaths,  89  ; 
or  1 in  4-9,  or  20*4  in  100,  died. 

Mortality  of  Individual  Amputations. 

Thigh  cases,  298  ; deaths,  107  ; or  1 in  2‘8  ; or  35-9  per  cent. 

Leg  „ 261  ; „ 69  ; or  1 in  3*7  ; or  26‘4  „ 

Arm  „ 138  ; .,  41  ; or  1 in  3'3  ; or  29-7  „ 

Forearm  „ 106  ; „ 1 1 ; or  1 in  9*6  ; or  10'3  „ 

SECOND  SERIES. 

Provincial  Hospitals  with  101  to  200  Beds. 

This  series  includes  twenty  hospitals.  Most  of  them  range  in 
number  of  beds  from  101  to  150.  Indeed,  only  one  hospital  on  the 
list  rises  to  a higher  number,  viz.  the  Sussex  County  Hospital, 
which  contains  165  beds.  There  are  four  hospitals  Avith  150  beds 
each;  and  six  with  120  beds  each.  The  hospitals  of  Leeds  and 
Nottingham,  and  the  Northern  Hospital  of  Liverpool,  yield  in  this 
series  the  largest  number  of  amputation  returns.  The  Infirmary  cf 
Liverpool,  a larger  institution  than  the  Northern  Hospital  of  that 
town,  is  included  in  the  preceding  or  first  series. 


394 


HOSPITALISM. 


Table  XXIII. — Results  of  the  Four  Amputations  of  the  Thigh,  Leg, 
Arm,  and  Forearm,  in  Twenty  British  Hospitals  containing  from 
101  TO  200  Beds. 


FOR  INJURY. 

FOR  disease. 

6 

Name  of  Hospital. 

05 

Years. 

Tliigh. 

Leg. 

Ann. 

Fore- 

arm. 

Thi] 

gh. 

Leg. 

Arm. 

Fore- 

arm. 

cr. 

o: 

03 

a 

03 

ff 

CC 

s 

"ct 

v: 

2 

C/3 

C/3 

05 

K 

W 

V3 

a 

W 

05 

cc 

C/3 

05 

CC 

rt 

c 

P- 

<v 

C 

ci 

Q 

o 

0. 

c 

O 

Q 

o 

o 

6 

u 

C 

c3 

a 

C- 

1 

Sussex  . . . 

165 

1862-68 

2 

1 

15 

7 

6 

1 

3 

0 

10 

6 

13 

2 

6 

0 

1 

0 

2 

Chester  . 

150 

1864-69 

5 

3 

16 

3 

6 

0 

5 

0 

1 

0 

5 

0 

1 

1 

0 

0 

3 

Bristol 

150 

1863-65 
& 1868 

9 

5 

6 

4 

2 

1 

2 

0 

18 

1 

8 

0 

0 

0 

2 

0 

4 

Derbyshire  . 

150 

1862-68 

10 

5 

15 

3 

1 ^ 

0 

2 

0 

13 

5 

16 

0 

2 

0 

6 

0 

5 

Norfolk  and  Nor- 

wich 

150 

1862-68 

9 

2 

11 

2 

2 

0 

15 

3 

23 

6 

10 

3 

9 

1 

5 

0 

6 

Radcliff,  Oxford 

149 

1862-68 

2 

1 

10 

3 

5 

0 

5 

0 

16 

1 

12 

2 

1 

1 

0 

0 

7 

Nottingham  . . 

142 

1862-68 

20 

5 

20 

3 

15 

2 

14 

1 

32 

5 

13 

2 

12 

2 

9 

0 

8 

Leeds  .... 

140 

1862-68 

18 

14 

43 

19 

41 

17 

55 

3 

44 

11 

35 

7 

12 

2 

7 

1 

9 

Shi-ewsbury  . . 

140 

1863-69 

13 

6 

20 

5 

20 

3 

6 

0 

14 

3 

14 

1 

3 

0 

4 

0 

10 

Liverpool,  North. 

134 

1862-68 

24 

16 

35 

12 

13 

4 

14 

3 

6 

2 

3 

1 

Ij 

1 

1 

0 

11 

Paisley  . 

132 

1862-68 

6 

0 

17 

2 

7 

1 

9 

0 

0 

0 

9 

2 

3 

0 

0 

0 

12 

No.  Staffordshire 

125 

1862-68 

13 

4 

41 

13 

12 

1 

6 

1 

15 

4 

7 

0 

0 

0 

0 

0 

13 

Inverness.  . . 

120 

1862-68 

1 

0 

4 

1 

0 

0 

1 

0 

2 

1 

1 

1 

1 

0 

2 

1 

14 

If 

Bath  Royal 

United . 

Reading  (Royal 

120 

1862-68 

3 

2 

5 

3 

5 

1 

1 

5 

0 

26 

7 

12 

2 

2 

0 

1 

0 

B.rkd.  . . 

120 

1862-68 

8 

1 

10 

2 

' 6 

0 

10 

3 

26 

3 

16 

0 

2 

0 

2 

0 

1( 

Liverpool,  South. 

120 

1862-68 

7 

2 

13 

6 

I 

5 

4 

0 

/ 

1 

8 

0 

4 

1 

1 

1 

n 

L^^ent  and  Canter- 

bury . 

120 

1862-68 

2 

1 

1 

0 

6 

0 

8 

0 

8 

0 

5 

1 

1 

0 

9 

0 

n 

Buxton  . . 

120 

1861-67 

1 

0 

1 

1 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

19 

Breen  ock . 

119 

1862-68 

9 

5 

5 

0 

11 

4 

1 

0 

1 

0 

1 

0 

1 

0 

0 

0 

20 

Rochester 

108 

1863-68 

5 

] 

4 

0 

1 ' 

0 

1 

2 

1 

3 

0 

0 

0 

1 

0 

Total . 

167 

74 

292 

89178  40 

16614 

264 

57 

191 

24 

61 

9 

51 

3 

Mortality  per  cent 

44-3 

30-4 

22-4 

8-4 

21-5 

12-5 

6-7 

5 

•9 

Or  proportionally  1 in  , . 

2-2 

3-2 

4-4 

11-8 

4-6 

8 

14-7 

17 

Total  number  of  cases,  1370  ; of  deaths,  310;  or  1 in  every 
4 ’4,  or  2 2 '6  in  every  100,  died. 

Total  number  of  amputations  for  injury,  803  ; of  deaths,  217  ; 
or  1 in  every  3*7,  or  27  in  every  100,  died. 

Total  number  of  amputations  for  disease,  567  ; of  deaths,  93  ; 
or  1 in  every  6T,  or  16 ‘4  in  every  100,  died. 

If  we  combine  together  the  amputations  for  injury  and  for  disease, 
the  mortality  from  the  individual  amputations  is  as  follows : — 


Mortality  of  Individual  Am^mtations. 


Thigh 

cases,  431  ; 

deaths,  131  ; 

or 

1 

in 

3-3  ; 

or 

30-4 

per  cent. 

Leg 

„ 483  ; 

55 

113  ; 

or 

1 

in 

4-2; 

or 

23-4 

55 

Arm 

■ „ 239  ; 

55 

49; 

or 

1 

in 

CO 

or 

20-5 

55 

Forearm 

. 217; 

55 

17  ; 

or 

1 

in 

12-7; 

or 

7-8 

55 

PROVINCIAL  HOSPITAL  AMPUTATIONS. 


395 


THIRD  SERIES. 

Provincial  Hospitals  with  26  to  1 00  Beds. 

This  list  includes  thirty  British  hospitals.  Four  of  them  contain 
40  ; three  of  them  50 ; three  of  them  60  ; three  of  them  90  ; and 
five  of  them  100  beds  each.  The  largest  numbers  of  amputations 
returned  in  this  series  are  from  two  hospitals  belonging  to  maritime 
towns — namely,  Plymouth  and  Cardiff. 

Table  XXIV. — Results  of  the  Four  Amputations  of  the  Thigh,  Leg, 
Arm,  and  Forearm,  in  Thirty  British  Hospitals  containing  from 
26  TO  100  Beds. 


d 

Name  of  Hospital. 

j No.  of  Beds. 

Years. 

FOR  INJURY. 

FOR  DISEASE. 

Tliigh. 

Le, 

D* 

Ann. 

Fore-; 
arm.  ! 

Thigli. 

Leg. 

Arm. 

Fore- 

arm. 

j Cases. 

1 Deaths.  | 

1 Cases. 

1 Deaths. 

j Cases. 

<u 

Q 

•Ji 

6 

1 Deaths. 

j Cases,  j 

1 Deaths.  | 

j Cases. 

1 Deaths. 

OJ 

V3 

O 

Cases. 

Deaths. 

1 

York  . . . . 

100 

1862-8 

4 

1 

2 

0 

1 

0 

1 

0 

5 

0 

5 

0 

4 

0 

1 

0 

2 

Worcester  . . 

100 

1863-8 

9 

4 

22 

0 

8 

0 

9 

1 

0 

0 

10 

1 

1 

0 

•2! 

1 

3 

Lincoln  County  . 

100 

1862-8 

6 

2 

5 

1 

5 

2 

4 

0 

11 

1 

8 

1 

4 

0 

4 

0 

4 

Dumfries . 

100 

1862-8 

2 

1 

5 

3 

4 

1 

2 

0 

2 

2 

9 

1 

3 

0 

0 

0 

5 

R.  South  Hants  . 

100 

1862-8 

3 

2 

7 

3 

2 

0 

8 

0 

8 

3 

2 

0 

2 

0 

3 

0 

6 

Salisbury . . . 

98 

1862-8 

7 

4 

2 

0 

4 

0 

1 

0 

17 

3 

4 

0 

4 

1 

8 

0 

,7 

Cheltenham  . . 

90 

1862-8 

5 

3 

5 

1 

4 

1 

1 

0 

7 

0 

3 

1 

0 

0 

0 

0 

8 

Plymouth  . . 

90 

1863-8 

13 

2 

10 

2 

7 

1 

5 

0 

9 

1 

2 

0 

2 

1 

4 

0 

9 

Taunton  . 

90 

1866-8 

1 

1 

2 

1 

2 

0 

4 

0 

3 

0 

0 0 

0 

0 

0 

0 

10 

Montrose . . . 

70 

1863-9 

1 

1 

0 

0 

2 

1 

0 

0 

5 

2 

0 

0 

1 

0 

4 

1 

11 

Lancaster  . . 

70 

1865-8 

2 

1 

7 

2 

1 

0 

3 

1 

0 

0 

0 

0 

0 

0 

0 

0 

12 

Truro .... 

60 

1862-8 

7 

2 

8 

0 

7 

0 

2 

0 

11 

0 

6 

0 

1 

1 

2 

0 

13 

Chichester  . 

60 

1862-9 

1 

0 

3 

0 

3 

2 

3 

0 

4 

1 

6 

3 

1 

0 

1 

0 

14 

North  Riding  . 

60 

1864-9 

4 

1 

7 

3 

2 

1 

1 

0 

1 

0 

4 

1 

1 

0 

0 

0 

15 

Royal  Surrey  Co. 

54 

1866-9 

5 

1 

1 

1 

1 

1 

0 

0 

4 

1 

2 

0 

0 

0 

2 

0 

16 

W.  Norfollc  and 

Lynn  . . 

52 

1862-8 

2 

1 

1 

0 

7 

1 

1 

0 

10 

2 

7 

1 

2 

0 

0 

0 

17 

Monkland  . . 

50 

0 

”0 

0 

0 

0 

0 

0 

0 

1 

0 

0 

0 

1 

0 

0 

0 

18 

Cardiff  . . 

50 

1862-9 

10 

4 

17 

6 

7 

0 

3 

0 

3 

0 

4 

1 

0 

0 

0 

0 

19 

Halifax  . 

50 

1862-8 

2 

1 

7 

3 

15 

|3 

7 

1 i 

6 

0 

10 

0 

1 

0 

0 

0 

20 

Balfour,  Kirkwall 

48 

0 

0 

0 

0 

1 

1 

3 

0 

6 

0 

9 

0 

0 

0 

1 

0 

21 

Huntingdon  . . 

42 

18’62-8 

3 

1 

4 

1 

3 

1 

2 

0 

3 

1 

3 

1 

2 

0 

0 

0 

22 

Denbigh  . . . 

40 

1862-9 

1 

1 

0 

0 

0 

0 

3 

1 

4 

0 

4 

1 

1 

0 

2 

0 

23 

Bridgewater  . 

40 

1862-8 

4 

2 

4 

0 

0 

0 

5 

1 

3 

1 

1 

1 

0 

0 

0 

0 

24 

Stamford . 

40 

1862-8 

3 

1 

2 

1 

2 

0 

1 

0 

8 

2 

3 

1 

1 

0 

1 

0 

25 

Carmarthenshire 

40 

1862-8 

2 

0 

7 

1 

1 

0 

1 

0 

0 

0 

1 

0 

0 

0 

3 

0 

26 

Hartlepool  . . 

36 

1865-9 

1 

0 

3 

0 

1 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

O' 

27 

Hertford  . 

35 

1863-9 

3 

1 

2 

1 

1 

0 

4 

0 

0 

0 

0 

0 

0 

0 

0 

0 

28 

Swansea  . 

34 

1862-8 

2 

1 

17 

3i 

' 6 

1 

1 

0 

2 

0 

7 

0 

2 

0 

1 

0 

29 

Great  Yarmouth 

28 

1862-9 

1 

0 

2 

1 

1 

0 

5 

0 

2 

0 

3 

0 

1 

0 

1 

0 

30 

Ramsgate 

26 

1865-8 

2 

0 

1 

0 

0 

0 

1 

0 

0 

0 

0 

0 

0 

0 

0 

0 

Total 

106 

39 

153 

34 

98 

81 

5 

135 

20 

113 

14 

35 

3 

40 

2 

Mortality  per  cent  . 

36-8 

22-2 

17-3 

16-1 

14 

12-4 

8-5 

5 

Or  proportionally  1 in  . 

2-7 

4-5 

5-7 

16-2 

6-7 

i 8 

11-6 

20 

396 


HOSPITALISM. 


Total  number  of  cases,  761  ; of  deaths,  134  ; or  1 in  every  5-6, 
or  17  6 in  every  100,  died. 

Total  number  of  amputations  for  injury,  438  ; of  deaths,  95  ; or 
1 in  every  4 ’6,  or  2T6,  in  every  100,  died. 

Total  number  of  amputations  for  disease,  323  ; of  deaths,  39  ; or 
1 in  every  8'3,  or  1 2 in  every  100,  died. 

If  we  combine  together  the  amputations  for  injury  and  for 
disease,  the  mortality  from  the  individual  amputations  is  as 
follows : — 

Mortality  of  Individual  Amputations. 

Thigh  cases,  241  ; deaths,  59  ; or  1 in  4 ; or  24*4  per  cent. 
Leg  „ 266  ; „ 48;  or  1 in  5-5;  or  18  „ 

Arm  „ 133 ; „ 20  ; or  1 in  6'Q  ; or  15  „ 

Forearm  „ 121  ; „ 7 ; or  1 in  17‘2;  or  5*8  „ 

FOURTH  SERIES. 

Provincial  Hospitals  with  25  Beds  and  under. 

This  series  includes  within  it  chiefly  the  so-called  Cottage 
Hospitals  of  Great  Britain.  They  have  been  usually  opened,  in  the 
first  instance  at  least,  in  houses  that  had  been  previously  used  as 
private  dwellings.  According  to  Mr.  ChurchiH’s  Directory,  the 
largest  “ cottage  hospital  ” in  England,  and  one  of  the  earliest,  is 
that  of  Middlesborough  in  Yorkshire,  which  contains  25  beds. 
Some  of  them  are  much  smaller.  The  hospitals  at  Fowey  in 
Cornwall,  and  Shedfield  in  Hampshire,  contain  only  four  beds  each ; 
and  that  of  Shotley  Bridge,  Durham,  though  it  is  only  provided  with 
five  beds,  has  already  a list  of  ten  limb-amputations.  The  first 
cottage  hospitals  in  England  were,  I believe,  founded  about  ten 
years  ago  ; and  one  or  two  of  the  returns  include  the  interval  from 
that  time  to  this.  But  most  of  them  are  much  later.  The  small 
general  Infirmaries  of  Kidderminster,  Bridgnorth,  and  Brecknock, 
which  contain  11  or  12  beds  each,  date  their  returns  from  1862. 


PROVINCIAL  HOSPITAL  AMPUTATIONS. 


397 


Table  XXV. — Eesults  of  the  Four  Amputations  of  the  Thigh,  Leg, 
Arm,  and  Forearm,  in  Seventeen  British  Hospitals  avith  25  Beds 

AND  UNDER. 


1 

Name  of  Hospital. 

No.  of  Beds. 

FOR  INJURY. 

•| 

FOR  DISEASE. 

Til 

gh. 

Leg. 

Ann. 

Fore- 

arm. 

Thi 

igh. 

Leg. 

Ann. 

Fore- 

arm. 

j Cases. 

Deaths. 

1 Cases. 

1 

j Deaths. 

j Cases.  1 

Deaths.  | 

1 Cases,  j 

1 Deaths. 

j Cases. 

Deaths. 

j Ca.ses. 

[ Deaths. 

CO 

ID 

V3 

a 

O 

Deaths. 

CO 

<D 

CO 

O 

1 Deaths.  | 

Middlesborough 

25 

3 

1 

20 

3 

7 

1 

0 

0 

1 

0 

6 

0 

1 

0 

0 

0 ! 

t Penrliyn . 

18 

0 

0 

0 

0 

0 

0 

1 

0 

0 

0 

0 

0 

0 

0 

0 

0 ! 

Barrow  . 

18 

1 

0 

2 

0 

4 

0 

4 

0 

0 

0 

0 

0 

0 

0 

0 

0 

Teigninouth . . 

17 

1 

0 

1 

1 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

Gravesend  . . 

15 

5 

1 

1 

1 

0 

0 

4 

2 

1 

0 

0 

0 

0 

0 

0 

0 

Kidderminster  . 

12 

0 

0 

5 

1 

3 

0 

5 

0 

0 

0 

0 

0 

0 

0 

0 

0 

Brecknock  . . 

12 

0 

0 

1 

0 

2 

0 

1 

0 

0 

0 

3 

0 

0 

0 

0 

0 

Bridgnorth  . 

11 

2 

1 

3 

1 

0 

0 

2 

0 

0 

0 

0 

0 

0 

0 

0 

0 

Saveinake  . 

10 

0 

0 

0 

0 

0 

0 

1 

0 

1 

0 

0 

0 

1 

.0 

0 

0 

Dinorwic . . 

8 

1 

0 

0 

0 

0 

0 

1 

0 

2 

0 

0 

0 

0 

0 

0 

0 

Cranleigh  . . 

6 

1 

0 

0 

0 

0 

0 

1 

1 

2 

1 

0 

0 

1 

0 

1 

0 

Shotley  Bridge  . 

5 

7 

2 

2 

1 

1 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

Fowey  . . . 

4 

3 

0 

1 

0 

0 

0 

0 

0 

0 

0 

2 

0 

0 

0 

0 

0 

Oswestry  . . 

0 

0 

1 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

Walsall  . . . 

24 

0 

0 

] 

0 

4 

0 

3 

0 

3 

1 

0 

0 

2 

1 

2 

0 

Shedfield . . . 

4 

0 

0 

0 

0 

1 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 1 

Ditchingham 

10 

0 

0 

0 

0 

0 

0 

1 

0 

0 

0 

0 

0 

0 

0 

0 

Total 

24 

5 

38 

8 

22 

24 

3 

10 

2 

17 

0 

5 

1 

3 

0 1 

Mortality  per  cent 

20-8 

21 

4-5 

12-5 

20 

0 

20 

0 1 

Or  proportionally  1 in 

4-8 

4-7 

22 

8 

5 

0 

5 

0 ; 

Total  number  of  cases,  143  ; of  deaths,  20  ; or  1 in  every  7T, 
or  14  in  every  100. 

Total  number  of  amputations  for  injury,  108  ; of  death,  17  ; or 
1 in  every  6'3,  or  15 ‘7  in  every  100. 

Total  number  of  amputations  for  disease,  35  ; of  deaths,  3 ; or 
1 in  every  11  *6,  or  8 ’6  in  every  100. 

If  Ave  combine  together  the  amputations  for  injury  and  for  dis- 
ease, the  mortality  from  the  individual  amputations  is  as  folloAvs  : — 

Mortality  of  Individual  Amputations. 


Thigh  cases, 

34; 

deaths, 

or  1 in  every 

4-8; 

or  2 O' 6 per  cent. 

Leg 

55  ; 

n 

8; 

or  1 in  every 

6-8  ; 

or  14'5  „ 

Arm  „ 

27; 

2 • 

} 

or  1 in  every 

13-5  ; 

or  7-4  „ 

Forearm  „ 

27; 

?) 

3; 

or  1 in  every 

9 ; 

or  11-1  „ 

The  three  first  series  of  provincial  hospital  returns  given  in  the  pre- 
ceding tables  contain  respectively  803,  1370,  and  761  limb-amputa- 


398 


HOSPITALISM. 


tions.  These  several  masses  of  data  afford  perhaps  in  each  series  a suffi- 
cient foundation  for  arriving  at  fair  and  reliable  statistical  inferences. 
In  the  fourth  series,  the  data  are  as  yet  too  small  for  coming  to  any 
very  certain  statistical  conclusions  on  the  subject ; and  a few  years 
will  need  to  elapse  before  our  cottage  hospitals  can  furnish  a suffi- 
cient basis  of  data  for  more  decided  and  determinate  results.  Per- 
haps the  data  which  already  exist  ought  to  give  a more  favourable 
view  of  the  salubrity  of  these  cottage  hospitals  for  operative  pur- 
poses than  the  last  of  the  preceding  series  of  tables  indicates.  For 
in  reference,  for  example,  to  the  “ Oswestry  Cottage  Hospital,”  Dr. 
Blaikie  has  returned  to  me  under  its  schedule  twelve  successful 
limb-amputations  without  a death,  though  I have  entered  only  one 
of  these.  This  is  the  only  case  that  has  occurred  in  the  newly 
opened  cottage  hospital  at  Oswestry  ; but  the  eleven  other  successful 
cases  had  previously  occurred  in  the  small  Workhouse  Infirmary  of 
Oswestry,  which  was  the  predecessor  of  the  cottage  hospital,  and 
may  justly,  perhaps,  be  assimilated  with  it,  and  placed,  as  is  done 
by  Dr.  Blaikie,  in  the  same  table.  Again,  in  consequence  of  it 
being  stated  in  Mr.  ChurchiH’s  Medical  Directory  that  the  Balfour 
Hospital  at  Kirkwall  contained  48  beds,  I entered  it  and  its  results 
in  the  third  of  the  preceding  tables  of  provincial  hospitals.  Since, 
however,  these  tables  were  calculated  and  finished,  I have,  in  a con- 
versation with  Dr.  Logie,  surgeon  to  the  hospital,  been  assured  by 
him  that  the  institution  has  never  had  above  1 2 beds,  though,  being 
established  in  a large  and  old  dwelling-house,  it  might  accommodate 
more  ; and  truly,  therefore,  it  belongs  to  the  series  of  cottage  hos- 
pitals. If  we  are  justified,  then,  in  adding  to  the  limb-amputations 
performed  in  hospitals  with  25  beds  or  less,  the  Oswestry  and  Kirk- 
wall returns,  instead  of  having  in  the  fourth  series  of  these  small 
provincial  hospitals  143  limb-amputations  with  20  deaths,  or  1 in 
every  7,  the  list  should  be  extended  to  174  cases  of  limb-amputa- 
tions with  21  deaths,  or  1 death  in  every  8. 

2.  The  Mortality  of  Limb-Amputations  as  regulated  by 
THE  Size  of  Hospitals,  and  the  degree  in  which  Patients 

ARE  AGGREGATED  OR  ISOLATED. 

In  Chapters  1.  and  11.  we  have  seen  that  in  our  large  metro- 
politan hospitals  about  41  in  every  100  operated  on  die  of  those 
patients  who  are  subjected  to  the  four  major  amputations  of  the 
limbs  j while  in  single  or  isolated  rooms  in  country  practice,  patients 


PROVINCIAL  HOSPITAL  AMPUTATIONS. 


399 


die,  under  the  very  same  class  of  operations,  to  the  extent  only  of 
10  or  11  in  every  100.  In  the  last  Chapter  we  have  collected  evi- 
dence of  the  death-rate  from  these  same  four  major  limb-amputa- 
tions in  British  provincial  hospitals  of  various  sizes.  If  we  throw 
the  whole  facts  thus  collected  into  a tabulated  form,  the  general 
results  may  be  stated  as  follows  : — 

Size  of  Hospital,  etc.  Death-rate. 

Is^  Series. — In  large  and  metropolitan  British  hospitals, 
chiefly  containing  from  300  to  500  beds  or  upwards, 
out  of  2089  limb-amputations  855  died,  or  . 1 in  24 

2d  Series. — In  provincial  hospitals  containing  from  201  to 

300  beds,  out  of  803  limb-amputations  228  died,  or  1 in  3 5 
Zd  Series. — In  provincial  hospitals  containing  from  101  to 

200  beds,  out  of  1370  limb-amputations  301  died,  or  1 in  44 
4dh  Series. — In  provincial  hospitals  containing  from  2G  to 

100  beds,  out  of  761  limb-amputations  131  died,  or  1 in  5 6 
bill  Series. — In  provincial  hospitals  containing  25  beds  or 

under,  out  of  143  limb-amputations  20  died,  or  1 in  7*1 

Qth  Series. — In  British  private  country  practice,  with  the 
patients  operated  on  in  single  or  isolated  rooms,  out 
of  2098  limb-amputations  226  died,  or  . 1 in  9*2 

These  data  go  to  point  out  and  establish  the  general  fact  or 
general  law  in  hospital  hygiene,  that  the  death-rate  accompanying 
amputation  of  the  limbs, — and,  as  we  may  infer,  the  death-rate 
accompanying  other  surgical  operations,  and  many  medical  diseases 
also, — is  regulated,  cceteris  imrihus,  in  a striking  manner  by  the  size 
of  the  hospitals,  and  the  degree  of  aggregation  or  segregation  in 
which  the  patients  are  treated.  But,  like  all  general  laws  in  medi- 
cine, this  law  is  subject  to  many  exceptions.  Thus,  a small  hos- 
pital, if  overcrowded  with  beds  and  patients,  becomes  as  insalu- 
brious as  a large  hospital  under  one  roof.  On  the  other  hand,  a 
large  hospital  would  be  generally  made  almost  as  salubrious  as  a small 
institution,  provided  few  beds  were  left  scattered  over  its  wards, 
and  these  wards  were  well  ventilated  and  often  changed.  But 
such  exceptions  only  establish  more  securely  the  great  hygienic  law, 
that,  in  the  treatment  of  the  sick,  there  is  ever  danger  in  their 
aggregation,  and  safety  only  in  their  segregation ; and  that  our 
hospitals  should  be  constructed  so  as  to  avoid  as  far  as  possible  the 
former,  and  secure  as  far  as  possible  the  latter  condition. 


400 


HOSPITALISM. 


CHAPTER  VI. 

HOW  OUR  PRESENT  HOSPITALS  COULD  BE  MOST  EASILY  ALTERED 
IN  ORDER  TO  RENDER  THEM  MORE  SALUBRIOUS. 

There  is  another  question  of  vast  moment  in  the  subject  of  hos- 
pitalism— namely,  How  could  our  present  older  hospitals  be  most 
simply  and  cheaply  changed  with  the  hope  of  improving  their 
insalubrious  character?  I have  elsewhere  commented  shortly  on 
this  subject.*  Perhaps  there  are  two  chief  methods  by  which  such 

^ The  following  is  the  comment  referred  to  : — 

“ The  idea  of  changing  our  hospitals,  in  order  to  increase  their  salubrity  and 
utility,  from  palaces — containing  aggregations  of  sick  in  each  flat — into  wooden, 
or  brick,  or  iron  villages,  is  one  which  I advocated  and  published  above  twenty 
yeacs  ago,  and  have  often  talked  of  and  discussed  since  that  time.  But  in  this 
country  it  has,  till  lately,  met  with  little  support.  Since  the  German  War,  how- 
ever, the  same  idea  has  been  reduced  to  practice  to  a small  initial  extent  in  that 
country,  in  consequence  of  military  exigencies  having  obliged  the  authorities  to 
place  the  sick  and  wounded  in  wooden  and  other  temporary  buildings,  which 
were  found  to  be  much  more  salubrious  than  their  mansioned  and  palatial  hos- 
]»itals.  To-day  I have  a letter  from  Professor  Gurlt,  of  Berlin,  in  which  he  states, 
ill  regard  to  the  present  use  of  huts,  cottages,  or  tents  around  some  of  the  chief 
hospitals  in  Germany,  “They  are  much  in  favour  with  us,  because  they  answer 
excellently  well,  and  give  excellent  results.  Besides  three  large  hospitals  (two 
civil  and  one  military)  in  Berlin,  they  are  used  in  Leipsic,  Heidelberg,  Darmstadt, 
Frankfort,  Kiel,  and  other  places.  There  is  now  a wooden  double-walled  hospital 
barrack  here  at  the  Charite  Hospital,  and,  as  far  as  I know,  also  at  Leipsic,  in 
constant  use  summer  and  winter,  heated  of  course  in  the  latter  by  large  stoves.” 
During  the  late  American  War  there  were  above  200  temporary  hosjntals  erected, 
containing  above  130,000  beds  ; more  than  one  million  patients  were  treated  in 
them  ; and  the  Surgeon-General  to  the  Army  of  the  United  States,  Dr.  Hammond, 
declared  that  they  were  found  “/«r  healthier  than  permanent  buildings.”  Why 
should  we  reject  in  civil  practice  means  found  so  much  better  and  healthier  in 
military  practice  ? 

“ If  hospitals  are  still  to  be  built  upon  a large  scale,  perhaps  means  may  be 
devised  to  invest  them  with  greater  safety  by  reducing  them  far  more  to  the 
character  of  separate  cottages  and  tenements,  by  each  ward  or  room  being  pro- 
vided with  a ventilation  separate  and  distinct.  This  has  been  already  accom- 
plished in  the  construction  of  some  of  the  new  blocks  of  tenements  for  artisans, 
lately  reared  in  London  and  elsewhere.  But  in  our  large  hospitals,  as  at  present 
constructed,  the  commixture  of  the  common  and  contaminated  air  in  wards,  stair- 
cases, corridors,  etc.,  utterly  prevents  this  desirable  consummation. — British 
Medical  Journal,  January  30,  1869.”  [Ed.J 


ALTERATION  OF  PRESENT  HOSPITALS. 


401 


a revolution  may  be  effected  arcliitectiirally : first,  by  making  the 
staircases,  corridors,  etc.,  all  open  ; or,  secondly,  by  building  up  the 
doors  and  entrances  of  the  wards  into  these  staircases,  corridors,  etc., 
and  by  making  an  entrance  into  each  ward  from  without.  One  or 
other  of  these  two  plans  would,  I believe,  suffice  for  the  improve- 
ment of  most  hospitals.  Other  and  better  plans,  however,  may 
possibly  be  devised. 

We  have  already  seen,  under  Proposition  XX.,  that,  in  conse- 
quence of  the  rapid  diffusion  of  light  and  aeriform  bodies  in  the 
atmosphere  of  an  hospital,  the  contents,  organic  and  inorganic,  which 
every  ward  contains,  and  the  exhalations,  cutaneous,  pulmonary,  etc., 
which  emanate  from  each  patient,  pass  out  of  the  wards  themselves 
to  the  corridors,  galleries,  staircases,  etc.,  of  the  house,  and  in  conse- 
quence of  all  the  wards  opening  into  them,  pass  and  repass  from 
one  to  the  other  in  a more  or  less  diluted  and  intermixed  form,  just 
as  if  the  whole  hospital  were  one  single  vast  chamber.  The  deterio- 
rated and  polluted  atmosphere  of  the  wards,  passing  freely  into  the 
staircases,  galleries,  etc.,  is  retained  and  imprisoned,  as  it  were,  there, 
and  liable  to  pass  onward  into  other  apartments  and  wards ; for 
there  is  generally,  as  is  well  known,  a double  and  contrary  current 
of  air  passing  at  different  heights  in  and  out  of  the  doors  of  such 
apartments.  When  the  foul  air  of  a house,  or  apartment,  or  ward, 
passes  out  directly  into  the  outer  atmosphere,  it  then  and  at  once 
loses  any  deleterious  properties  belonging  to  it,  because  it  is  swiftly 
diffused  through  the  almost  ever-moving  and  ever-changing  external 
air,  in  which  a rapid  system  of  self-purification  is  constantly  going 
on.  By  having  the  staircases,  corridors,  galleries,  etc.,  of  an  hospital 
freely  open  to  the  external  air,  and  by  thus  permitting  the  external 
air  to  be  constantly  passing  and  sweeping  through  them,  would  we 
not  attain  two  great  objects'? — First,  the  avoidance  of  the  retention 
and  imprisonment  to  a greater  or  lesser  degree  of  the  ‘ internal 
befouled  hospital  air  in  these  staircases,  corridors,  galleries,  etc.,  with 
the  chance  of  its  repassing  in  its  deteriorated  state  into  other  wards ; 
and,  secondly,  the  filling  and  occupation  of  the  staircases  and  other 
spaces  with  air  having  all  the  purity  and  purifying  powers  of  the 
external  atmosphere.  The  degree  to  which  this  latter  important 
object  could  be  obtained  in  each  individual  hospital  would  depend, 
of  course,  upon  the  degree  to  which  the  staircases,  passages,  etc., 
were  freel}'-  and  fully  opened  up.  The  permanent  opening,  in  half 
or  in  whole,  of  a single  window  or  two  in  a staircase,  or  corridor,  or 
gallery,  would  perhaps  do  much;  but  the  permanent  opening  of  all 


402 


HOSPITALISM. 


the  windows  would  do  far  more.  If  ever,  in  order  to  render  the 
opening  of  these  staircases,  galleries,  etc.,  more  full  and  free,  the 
removal  of  a portion  of  their  containing  or  outer  wall  was  required 
to  be  adopted  in  some  instances,  this  would  be,  after  all,  doing 
nothing  more  than  what  has  recently  been  effected  in  the  building 
schemes  of  Sir  Sidney  Waterlow  and  other  philanthropists  in  the  con- 
struction, in  London  and  elsewhere,  of  blocks  of  houses  for  artisans, 
the  flats  being  connected  by  open  staircases,  and  each  flat  being  pro- 
vided with  an  open  balcony,  in  which  balcony  all  the  doors  of  the  tene- 
ments of  that  flat  have  their  entrance.  If  an  hospital  were  so  altered 
as  here  suggested,  the  entrance  of  each  ward  from  the  stair-landings, 
corridors,  etc.,  would  probably  require  to  be  provided  with  double 
doors,  to  protect,  when  necessary,  against  gusts  of  wind  and  cold. 

It  is  not  my  object  here  to  discuss  the  question  how  each  sepa- 
rate ward  may  be  best  and  most  thoroughly  ventilated.  Many 
artificial  plans  have  been  proposed,  and  have  been  attempted  to  be 
put  in  practice ; but  all  these  artificial  plans  have  hitherto,  it  must 
be  confessed,  ended  in  failure.  We  can  readily  send  in  carburetted 
hydrogen  gas  by  tubes  into  houses  and  rooms  from  great  distances 
for  the  purpose  of  lighting  ; and  some  similar  simple  plan  of  pouring 
into  every  inhabited  chamber,  even  in  our  crowded  cities,  an  ade- 
quate and  continuous  stock  of  fresh  and  country  atmospheric  air,  may 
yet  betimes  be  fallen  upon ; but  up  to  the  present  hour,  no  artificial 
system  of  perfectly  and  successfully  ventilating  individual  wards  has 
been  suggested,  and  the  “ natural  system”  of  ventilation  by  fire- 
places, and  opposite  and  partially-opened  windows,  is  chiefly,  and  in 
most  instances  entirely,  depended  upon. 

Instead  of  opening  up  staircases,  corridors,  etc.,  if  they  were  left 
in  their  present  condition  in  some  hospitals,  perhaps  the  perfect 
isolation  and  ventilation  of  the  individual  wards  could  be  effected 
more  perfectly  in  the  following  manner : — Build  up  the  doors,  and 
any  other  entrances  from  the  wards  into  the  stair-landings,  corri- 
dors, etc.,  and  make  all  the  wards  and  all  the  flats  be  entered  from 
without,  either  by  new  external  staircases,  if  the  hospital  were  not 
above  two  storeys  in  height,  or  by  covered  balconies  or  galleries 
placed  upon  the  outer  wall  of  the  ward,  and  to  which  balconies  or 
galleries  entrance  was  given  by  the  existing  staircases.  If  every 
ward  Avere  thus  prevented  from  sending  its  deteriorated  air  into  the 
interior  of  the  house,  Avith  the  mischance  of  polluting  the  general 
atmosphere  of  the  hospital,  and  if  itself  it  had  only  communication 
with  the  external  atmosphere,  then  each  Avard  Avould  become  a 


ALTERATION  OF  PRESENT  HOSPITALS. 


403 


separate  cottage  hospital,  as  it  were,  with  a self-ventilation  entirely 
its  own.  The  perfection  or  imperfection  of  that  self-ventilation 
would  depend  upon  the  number  and  position  of  its  fires,  windows, 
etc.  ; but  its  contained  patients  would  be  freed  from  the  danger  of 
breatliing  an  air  contaminated  by  the  emanations  and  exhalations 
from  the  patients  in  the  other  wards  of  the  institution.  One  of  the 
end  windows  in  each  ward  would  of  course,  on  this  principle, 
require  to  be  changed  into  a door-entrance,  and  to  be  duly  protected 
by  being  provided  either  with  a double  door,  or  by  being  made  to 
open  into  a small  end  room,  such  as  are  found  in  almost  all  hospital 
wards.  These  balconies,  connecting  these  ward-doors  with  doors 
made  by  the  removal  of  a window  on  the  stair-landing  or  a stair- 
case, could  perhaps  be  cheaply  and  strongly  enough  made  of  iron, 
and  covered  with  it  or  other  material. 

An  hospital,  if  changed  on  this  plan,  would  still  have  its  internal 
staircases,  corridors,  wards,  etc.,  as  before  ; but  instead  of  having  the 
air  belonging  to  all  of  its  interior  fully  and  dangerously  intermixed, 
it  would  have  every  ward  changed  into  a separate  and  self-ventilating 
apartment,  opening  and  sending  its  air  only  to  the  external  atmo- 
sphere, and  deriving  its  own  air  only  from  that  external  atmosphere. 
Its  wards  would  be  a series,  so  far,  of  self-ventilated  cottage  hos- 
pitals, each  in  its  ventilation  perfectly  isolated,  and  separate  from 
and  independent  of  all  the  others  that  belonged  to  the  institution. 

In  the  late  American  and  German  wars,  small  military  hospitals 
consisting  of  canvas  tents,  wooden  cottages  or  barracks,  and  single- 
storeyed buildings,  erected  of  various  materials  for  hospital  purposes, 
have  been  employed  to  a much  greater  extent  than  I believe  they 
ever  previously  were.  Subsequently  to  the  battle  of  Sadowa,  and 
after  many  of  the  palatial  hospitals  in  various  cities  of  Germany  had 
been  so  filled  with  the  wounded  and  sick  that  they  could  hold  no 
more,  the  overplus  was  placed  in  various  hospital  grounds  and  else- 
where, in  canvas  tents,  and  wooden  sheds  or  barracks  erected  for  the 
purpose.  The  treatment  of  the  patients  jdaced  in  these  small  cot- 
tage barracks  and  tents  proved  so  much  more  successful  than  the 
treatment  of  similar  patients  who  were  lodged  in  the  olden,  many- 
storeyed,  palatial  hospitals,  that  latterl}*,  in  various  and  extensive 
cities  in  Germany — as  Berlin,  Dresden,  Kiel — erections  of  the  same 
unsubstantial  kind  have  been  reared  around  many  of  the  old  hos- 
pitals, and  employed,  because,  as  proved  by  military  medical  experi- 
ence, they  seem  to  afford  far  more  salubrious  dwellings  for  surgical 
and  medical  patients  than  the  olden,  many-storeyed  hospital  mansions. 


404 


HOSPITALISM. 


In  Other  words,  what  proved  so  serviceable  in  military  surgery  and 
medicine  as  an  hospital  arrangement,  has  been  adopted  already,  to 
a considerable  extent,  in  civil  surgery  and  medicine  also.  They  have 
been  tried  also  to  a slighter  extent  in  Paris.  With  what  results'? 
Success  of  canvas,  wooden,  etc.,  cottage  hospitals. 

Cottage  hospitals  of  double  canvas  and  w^ood  — soine  of  the 
latter  so  formed  and  built  as  to  serve  in  Avinter  as  well  as  summer 
— have  been  more  largely  employed  in  Germany  than  in  France. 
When  Avriting  to  me  lately  on  the  subject  of  these  German  cottage 
hospitals.  Professor  Gurlt  of  Berlin  remarks  — “ In  regard  to  the 
experiences  made  in  Berlin,  and  elseAvhere  in  Germany,  I can  assure 
you  positively  that  the  tent  and  barrack  hospitals  have  proved  with 
us  more  salubrious  and  less  deadly  than  the  large  palatial  hospitals. 
But,  nevertheless,  it  must  be  added,  that  cases  of  septicaemia  must 
occasionally  occur  in  them  as  everyAvhere  else,  being  dependent  in 
part  upon  the  severity  of  the  lesion  in  itself  (as  we  have  seen  by  far 
too  often  during  the  last  Avar,  under  the  most  favourable  external 
circumstances).  Pyaemia  occurs  also  sometimes  in  them  ; the  oftener 
the  more  the  season  is  unfavourable  and  admits  of  no  sufficient 
ventilation  by  a free  access  of  air ; and  the  longer  also  the  barrack  or 
tent  is  in  continual  use,  and  the  more  severe  cases  are  accumulated 
in  them.  There  cannot,”  Dr.  Gurlt  adds,  “ be  any  doubt  that  every 
porous  material,  stone,  wood,  canvas,  etc.,  Avhich  may  be  employed 
for  hospitals,  must  become  infected  betimes,  and  the  rooms  must  be 
emptied  therefore,  pro  tempore,  and  cleaned  Avith  the  utmost  care.” 

UpAvards  of  tAventy  years  ago,  in  publishing  a Keport  of  the 
Edinburgh  Maternity  Hospital,  I took  occasion  to  suggest  the  ad- 
vantages the  village  or  cottage  system  Avould  have  over  our  present 
palatial  hospitals.^ 

Several  years  afterwards,  in  publicly  discussing  the  same  subject, 
I spoke  to  the  questions — “ To  Avhat  extent  are  hospitals,  as  in  general 
at  present  constituted,  banes  or  blessings?  and  how  can  they  be 
changed  so  as  to  convert  them  from  the  former  to  the  latter?”  And 
I concluded  by  again  suggesting  that,  to  gain  sufficient  room  and  air 
and  isolation  for  the  sick  inmates,  they  should  be  altered  “from  Avards 
into  rooms,  from  stately  mansions  into  simple  cottages,  from  stone 
and  marble  palaces  into  Avooden  and  brick  and  iron  villages.”' 

“ Although  the  establishment  of  hospitals  is  a necessity  and 

^ Edinburgh  Monthly  Journal  of  Medical  Science  for  NoA’cmber  1848,  p.  328. 
Already  quoted  ante,  p.  290.  [Ed.] 

2 Transactions  of  the  Social  Science  Association  for  1867,  p.  115. 


ALTERATION  OF  PRESENT  HOSPITALS. 


405 


marks  tlie  era  of  an  advanced  civilisation,  it  must  always  be  remem- 
bered that,  if  the  crowding  of  healthy  men  has  its  danger,  the 
bringing  together  within  a confined  area  of  many  sick  persons  is  far 
more  perilous.  The  risks  of  contamination  of  the  air  and  of  impreg- 
nation of  the  materials  of  the  building  with  morbid  substances,  are 
so  greatly  increased,  that  the  greatest  care  is  necessary  that  hospi- 
tals should  not  become  pesthouses,  and  do  more  harm  than  good. 
We  must  always  remember,  indeed,  that  a number  of  sick  persons 
are  merely  brought  together  in  order  that  medical  attendance  and 
nursing  may  be  more  easily  and  perfectly  performed.  The  risks  of 
aggregation  are  encountered  for  this  reason ; otherwise  it  would  be 
fiir  better  that  sick  persons  should  be  separately  treated,  and  that 
there  should  be  no  chance  that  the  rapidly  changing,  and  in  many 
instances,  putrefying  substances,  of  one  sick  body,  should  pass  into 
the  bodies  of  the  neighbouring  patients.  There  is,  indeed,  a con- 
tinual sacrifice  of  life  from  diseases  caught  in  or  aggravated  by 
hospitals.  The  many  advantages  of  hospitals  more  than  counter- 
balance this  sacrifice,  but  it  should  be  the  first  object  to  lessen  the 
chance  of  injury  to  the  utmost.  The  risk  of  transference  or  aggra- 
vation of  disease  is  least  in  the  best  ventilated  hospitals.  A great 
supply  of  air,  by  immediately  diluting  and  rapidly  carrying  away 
the  morbid  substances  evolved  in  such  quantities  from  the  bodies 
and  excretions  of  the  sick,  reduces  the  risk  to  its  minimum,  and 
perhaps  removes  it  altogether.  But  the  supply  of  air  must  be  enor- 
mous. We  are  not  in  a position  to  say  how  much ; but  I question 
whether  even  the  large  quantity  of  4000  cubic  feet  per  head  per 
hour,  now  assigned  by  the  best  observers,  will  not  be  found  to  be 
far  below  the  proper  amount  for  the  acute  and  febrile  diseases.” 


HEEMAPHEODITISM. 


Hermaphroditism,  or  Hermaphrodism ; * Ilermaphrodisia ; an- 
drogynismej  gynandrisme ; liermaphroditisme,  etc.,  of  the  French ; 
erniaphrodismo  of  the  Italians  ; Zicitterhildung  of  the  Germans,  etc. 

Many  different  definitions  of  hermapliroditism,  and  almost  an 
equal  number  of  different  classifications  of  the  malformations  usually 
comprehended  under  it,  have  been  proposed  by  the  various  authors, 
ancient  and  modern,  who  have  directed  their  attention  to  this  subject. 
Without  stopping  to  discuss  the  merits  or  errors  of  these  definitions 
and  classifications,  and  without  inquiring,  as  some  have  done,  into 
the  propriety  of  the  w^ord  itself,  we  shall  content  ourselves  with 
stating  that,  under  it,  as  a convenient  generic  term,  we  purpose  in 
the  present  article  to  include  an  account — Is/,  of  some  varieties  of 
malformation  in  which  the  genital  organs  and  general  sexual  con- 
figuration of  one  sex  approach,  from  imperfect  or  abnormal  develop- 
ment, to  those  of  the  opposite ; and,  '2d,  of  other  varieties  of 
malformation,  in  which  there  actually  co-exist  upon  the  body  of  the 
same  individual  more  or  fewer  of  the  genital  organs  and  distinctive 
sexual  characters  both  of  the  male  and  female. 

To  separate  from  one  another,  bj'’  as  strong  a line  as  possible,  the 
two  distinct  varieties  of  hermaphroditic  malformation  marked  out  in 
this  definition,  we  shall  divide  hermaphroditic  malformations,  con- 
sidered as  a class,  into  the  two  orders  of  Spurious  and  True;  the 
spurious  comprehending  such  malformations  of  the  genital  organs 
of  one  sex  as  make  these  organs  approximate  in  appearance  and 
form  to  those  of  the  opposite  sexual  type ; and  the  order,  again,  of 
true  hermaphroditism  including  under  itself  all  cases  in  which  there 
is  an  actual  mixture  or  blending  together,  upon  the  same  individual, 
of  more  or  fewer  of  both  the  male  and  female  organs. 

Spurious  hermaphroditism  may  occur  cither  in  the  male  or 

^ From  the  well-known  mythological  fable  of  the  union  into  one,  of  the  bodies 
of  Hermaphroditos,  the  son  of  Mercury,  and  ’Acppodirr],  Venus,  and  the 

nymph  Salmacis. — See  Ovid’s  Metamorphoses,  lib.  iv'.  fab.  8. 


408 


HERMAPHRODITISM. 


female ; that  is,  there  may  be,  from  malformation  of  the  external 
sexual  organs,  an  appearance  of  hermaphroditism  in  persons  actually 
of  the  female  sex,  or  from  a similar  cause  there  may  be  an  appear- 
ance of  hermaphroditism  in  persons  actually  of  the  male  sex.  The 
dilferences  derived  from  the  diversity  of  sex  in  which  spurious  her- 
maphroditism occurs,  and  the  particular  varieties  of  malformation  in 
each  sex  which  may  give  rise  to  it,  will  serve  as  bases  on  which  we 
shall  found  some  further  subdivisions  of  this  order. 

True  hermaphroditism,  as  above  defined,  comprehends  also,  as 
will  afterwards  be  more  particularly  shown,  several  very  listinct 
varieties  of  malformation.  If  we  conceive  for  a moment  all  the 
reproductive  organs  to  be  placed  on  a vertical  plane,  as  we  may 
suppose  them  to  be,  though  not  with  strict  correctness,  in  the  human 
body  when  in  the  erect  posture,  we  shall  find  that  the  principal  of 
these  varieties  may  be  all  referred  to  three  sets  of  cases  : — Is^,  those 
in  which,  if  we  draw  a vertical  median  line  through  this  supposed 
plane,  the  two  lateral  halves  are  seen  to  present  organs  differing  in 
this  respect,  that  they  belong  to  opposite  sexual  types ; 2d,  others 
in  which,  if  we  bisect  the  same  plane  by  a transverse  horizontal  line, 
there  exist  organs  of  a different  sex  in  the  upper  from  those  present 
in  the  lower  segment ; or,  in  other  words,  in  which  the  internal 
genital  organs  belong  to  one  sex,  and  the  external  to  another.  In 
the  two  preceding  classes  of  cases  there  is  not  necessarily,  as  we 
shall  afterwards  more  fully  point  out,  any  malformation  by  duplicity 
in  the  sexual  apparatus  of  the  malformed  individual ; there  is  only 
one  set  of  sexual  organs  present,  but  in  some  parts  these  organs  are 
formed  upon  the  male,  and  in  others  upon  the  female  type.  In  the 
3d,  and  remaining,  set  of  cases,  however,  there  is  really  present  to  a 
greater  or  less,  though  most  generally  only  to  a very  partial,  extent, 
a double  set  of  sexual  organs,  having  opposite  sexual  characters  so 
that  upon  the  same  body,  and  usually  upon  the  same  side,  or  upon 
the  same  vertical  line  in  our  supposed  plane,  we  find  co-existing  two 
or  more  of  the  analogous  organs  of  the  two  sexes.  In  accordance 
Avith  this  view,  we  shall  consider  the  cases  of  true  hermaphroditic 
malformation  under  the  three  corresponding  divisions  of — 1st, 
lateral;  2d,  transverse;  and  3d,  vertical,  or  more  properly,  double  or 
complex  hermaphroditism,;  and  each  of  these  genera  will  admit  of 
some  further  convenient  subdivisions.  But  the  mode  in  AAdiich  we 
propose  to  classify  and  consider  the  subject  Avill  probably  be  at  once 
more  accurately  gathered  from  the  folloAving  table,  than  from  any 
more  lengthened  remarks  upon  it  in  the  present  place. 


VARIETIES  OF  HERMAPHRODITISM. 


409 


Classification  of  Hcrvfiapliroditic  Malformations, 


Spurious, 


From  excessive  development  of  the 
clitoris,  etc. 

From  prolapsus  of  the  uterus. 

( From  extroversion  of  the  urinary 
bladder. 

In  the  Male  ■!  adhesion  of  the  penis  to  the 

^ ^ ) scrotum. 

From  hypospadiac  fissure  of  the 
t urethra,  etc. 


f In 
1 the  Female 


Hermaphroditism  -j 


.True, 


{ Testis  on  the  right,  and  ovary  on 
T -ifprol  ) side. 

1 Testis  on  the  left,  and  ovary  on  the 
( right  side. 

{ External  sexual  organs  female,  in- 
1 ternal  male. 

transverse.  < External  sexual  organs  male,  inter- 
f nal  female. 


Vertical  or 
Double... 


f Ovaries  and  an  imperfert  uterus, 
with  male  vesiculie  seminales,  and 
rudiments  of  vasa  deferentia. 

- Testicles,  vasa  deferentiii,  and  vesi- 
culse  seminales,  with  an  imperfect 
I female  uterus  and  its  appendages, 

I Ovaries  and  testicles  co-existing  on 
one  or  both  sides,  etc. 


In  commenting  upon  and  illustrating  the  different  varieties  of 
hermaphroditism,  in  the  particular  order  in  which  they  are  placed  in 
the  above  table,  we  shall,  we  believe,  by  following  that  order,  be 
able  to  take  a graduated,  and,  at  the  same  time,  a correct  and  com- 
prehensive view  of  the  subject,  beginning  with  the  more  simple,  and 
ending  with  the  more  complex  and  complete  species  of  hermaphro- 
ditic malformation,  as  seen  in  the  primary  sexual  characters,  or  the 
structure  of  the  genital  parts  themselves.  We  shall  then  consider  at 
some  length  the  curious  and  important  physiological  subject  of  her- 
maphroditism as  manifested  in  the  secondary  sexual  characters  of 
the  system.  After  having  done  so,  we  shall  endeavour  to  show  how 
far  the  diversified  forms  of  hermaphroditic  malformation  can  be 
explained  upon  our  present  knowledge  of  the  laws  of  development ; 
point  out  the  actual  anatomical  and  physiological  degree  of  sexual 
duplicity  which  is  liable  to  occur,  and  the  numerous  fallacies  with 
which  the  determination  of  this  question  in  individual  cases  is  sur- 
rounded ; and  lastly,  in  conclusion,  we  shall  offer  some  general 
observations  upon  the  causes,  etc.,  of  this  class  of  abnormal  for- 
mations. 


410 


HERMAPHRODITISM. 


A. — SPURIOUS  HERMAPHRODITISM  IN  THE  FEMALE. 

There  are  two  circumstances  in  the  conformation  of  the  genital 
organs  of  the  female,  the  existence  of  each  of  which  has  occasionally 
given  rise  to  doubts  and  errors  with  regard  to  the  true  sex  of  the 
individual  on  whom  they  were  found — namely,  Is^,  a preternaturally 
large  size  of  the  clitoris ; and  2d,  a prolapsus  of  the  uterus ; the 
enlarged  clitoris  in  the  one  case,  and  the  protruded  uterus  in  the 
other,  having  been  repeatedly  mistaken  for  the  male  penis. 

1.  Abnormal  development  or  magnitude  of  the  clitoris. — In  the 
earlier  months  of  intra-uterine  life,  the  clitoris  of  the  human  female 
is  nearly,  if  not  altogether,  equal  in  size  to  the  penis  of  the  male 
foetus  ; and  at  birth  it  is  still  relatively  of  very  considerable  dimen- 
sions. From  that  period,  however,  it  ceases  to  grow  in  an  equal 
ratio  with  the  other  external  genital  parts,  so  that  at  puberty  it  is, 
as  a general  law,  found  not  to  exceed  six  or  eight  lines  in  length. 
But  in  some  exceptional  instances  the  clitoris  is  observed  to  retain 
up  to  adult  age  more  or  less  of  that  greater  proportionate  degree  of 
development  which  is  presented  in  the  embryo  of  the  third  and 
fourth  month,  thus  exhibiting  in  a persistent  form  the  transitory 
type  of  structure  belonging  to  the  earlier  stages  of  foetal  life.  In 
some  instances  where  this  occurs,  the  resemblance  of  the  external 
female  to  the  external  male  parts  is  occasionally  considerably  in- 
creased by  the  apparent  absence  of  the  nymphie.  Osiander^  en- 
deavoured to  show  that  at  the  third  or  fourth  month  of  foetal  life 
the  nymphse  are  very  imperfect,  and  so  very  small  as  not  to  be 
easily  observed.  Meckel,^'  however,  has  pointed  out  that  these  organs 
are  not  in  reality  of  a small  size  at  that  time,  but  they  are  liable  to 
escape  observation  from  the  folds  of  skin  of  which  they  consist, 
making,  at  the  period  alluded  to,  a perfectly  continuous  membrane 
with  the  prepuce  of  the  clitoris,  and  forming  indeed,  in  their  origin, 
only  one  common  mass  with  this  latter  body.  When  the  ulterior 
changes,  therefore,  which  these  parts  ought  to  undergo  in  the  natural 
course  of  development  in  the  latter  stages  of  foetal  existence,  are 
suspended  or  arrested  from  about  the  end  of  the  third  month,  there 
may  not  only  co-exist  with  the  enlarged  clitoris  an  apparent  want 
of  nymphse,  but  the  resemblance  of  the  female  to  the  male  parts 
may  be  still  further  increased  by  the  persistence  of  the  original  in- 

^ Ahhandhingen  ubcr  die  Schcidcnklappe,  in  Dcnkwurdighcitcn  fur  die  Heil- 
kunde,  BJ.  ii.  pp.  4-6. 

2 Manuel  d’Anat.  Gen.  tom.  iii.  p.  666. 


SPURIOUS  IN  FEMALES. 


411 


timate  connection  of  the  nymplne  with  the  prepuce  and  body  of  the 
clitoris,  and  by  the  consequently  continuous  coating  of  integuments, 
as  well  as  the  greater  size  and  firmness  of  this  organ. 

Excessive  size  of  the  clitoris  would  seem  to  be  much  less  com- 
mon among  the  natives  of  cold  and  temperate  than  among  those  of 
warm  countries.  The  frequency  of  it  in  the  climate  of  Arabia  may 
be  surmised  from  the  fact  of  directions  having  been  left  by  Albucasis 
and  other  surgeons  of  that  country  for  the  amputation  of  the  organ  ; 
an  operation  which  uTitius  and  Paulus  ^ginetus  describe  as  also 
practised  among  the  Egyptians.  According  to  the  more  modern 
observations  of  Niebuhr  ^ and  Sonnini,*  circumcision  would  seem  to 
be  still  practised  upon  the  females  of  that  country. 

This  variety  of  conformation  of  the  female  parts  appears  to  have 
been  well  known  to  the  ancient  Greeks,  and  several  of  their  authors 
have  mentioned  the  women  so  constituted  under,  the  names  of 
and  a class  in  which  the  celebrated  poetess 

Sappho  {inascula  Sappho)  is  well  known  to  have  been  included. 
Martial,  Tertullian,  and  other  Roman  authors  have  noticed  the  same 
malformation  (friccdi-ices,  confricatrices),  and  have  alluded  to  the 
depravity  to  which  it  led.^ 

^ Beschrcibung  von  Arabien,  s.  77. 

2 Voyage  dans  la  Haute  et  Basse  Egypte,  tom.  ii.  p.  37. 

^ Mart.  Epigr.  lib.  i.  ep.  91  ; see  also  lib.  viii.  ep.  66.  The  frequency  of  this 
crime  in  the  ancient  gentile  world  may  be  inferred  from  the  pointed  manner  in 
which  the  Apostle  Paul  alludes  to  it,  Romans,  chap.  i.  26.  In  Greece  it  was  in 
some  places  forbidden  by  law,  and  in  others,  as  in  Crete,  tolerated  by  the  state. 
Seneca,  in  his  9oth  ep.,  when  speaking  of  the  depravity  of  the  women  of  his  own 
age,  remarks,  “ non  mutata  foeminarum  natura,  sed  vita  est.  . . . Libidine  vero, 
nec  maribus  quidem  cedunt  pati  natse.  Dii  illas  deaeque  male  perdant,  adeo  per 
versum  commentae  genus  impudicitise  viros  ineunt.”  Op.  Om.  Genev.  1665,  p,  787. 
Clemens  Alexandrinus,  in  his  Pa^dagogus,  exposes  the  same  vice  ; “ et  contra  natu- 
ram  fceminae,  viros  agunt  {apdpi^ovrai)  et  nubunt  etetenim  uxores  ducunt.”  Also 
Athenaeus,  Eeijmosoph.  lib.  xiii.  p.  605.  Justin  Martyr,  in  his  Second  Apology, 
makes  a still  broader  accusation.  This  author  lived  in  the  second  century,  and  in 
declaiming  against  the  vices  of  that  licentious  age,  he  alleges  that  multitudes  of 
boys,  females,  and  hermaphrodites  {androgyni  ambigui  sexus)  “ nefandi  piaculi 
gratia  per  nationem  omnem  prostant.  ” Op.  Om.  Col.  1686,  p.  70.  See  also 
Marcus  Antoninus,  De  Scipso,  ed.  Gatakeri,  Cambr.  1652,  lib.  iii.,  note  at  the 
end  by  Gataker.  On  the  extent,  among  the  ancients,  of  the  vices  above  alluded 
to,  see  Meiner’s  Geschichte  dcs  Vcrfalls  dcr  Sitten  mid  der  Slaatsvcrf assung  dcr 
liocmer,  Leipzig,  1791  ; Neander’s  Denkwiirdiglceitcn,  Bd.  i.  s.  143  ; Professor 
Tholuck’sof  Halle  “Exposition  of  St.  Paul’s  Epi.stle  to  the  Romans,”  in  the  Edin- 
burgh Biblical  Cabinet,  vol.  v.  p.  102,  and  in  an  Essay  on  the  licentious  vices, 
etc.,  of  the  Ancients,  translated  into  Robinson’s  American  Biblical  Repository,  vol. 
ii.  p.  441.  In  the  essay  last  referred  to,  Tholuck  incidentally  mentions  (jn  422) 
that  the  Deity  Mitra  (Mithras  of  the  Ancient  Persians)  was  hermaphrodite.  For 


412 


HERMAPHRODITISM. 


The  dimensions  which  the  clitoris  occasionally  presents  are  such 
as  to  render  it,  in  respect  of  size  alone,  not  unlike  the  male  penis. 
It  is  not  unfrequently  found  of  two  or  three  inches  in  length,  but 
sometimes  it  is  seen  five  and  six  inches  long.  Dr.  Clark  frequently 
found  the  organ  an  inch  long,  and  thick  in  proportion,  among  the 
Ibbo  and  Mandingo  women. ^ 

Haller,^  and  Arnaud^  have  collected  numerous  instances  of  pre- 
ternatural size  of  the  clitoris.  The  former  author  alludes,  among 
others,  to  two  cases  in  which  the  organ  was  stated  to  have  been 
seven  inches  in  length  ; and  to  another,  mentioned  by  Chabart,  in 
which  it  was  alleged  to  have  been  twelve  inches — a size  which  we 
can  only  conceive  to  have  been  the  result  of  disease. 

When  the  female  clitoris  is  increased  greatly  in  size,  it  is  not 
wonderful  that  it  should  be  sometimes  mistaken  for  the  male  penis 
— the  female  organ  in  the  Mammalia  naturally  differing  from  the 
male  only  in  regard  to  its  smaller  dimensions,  its  not  being  per- 

oiir  own  part,  Ave  are  inclined  to  believe  that  many  of  the  idols  of  the  heathenish 
mythology  of  Asia  could  be  traced  to  the  deification  of  various  monstrosities  in 
man  and  quadrupeds.  (See  the  figures  of  these  idols  passim  in  Coleman’s  Myth- 
ology of  the  Hindus,  Lond.  1832  ; and  Upham’s  History  and  Doctrine  of  Buddhism, 
Lond.  1829.)  It  is  perhaps  not  unworthy  of  notice  that  the  Jewish  Talmudists, 
taking  the  Hebrew  noun  in  the  Pentateuch  answering  to  man  in  its  individual 
and  not  in  its  collective  sense,  considered  from  Genesis,  chap.  i.  21,  that  our 
original  progenitor  was  hermaphrodite.  (See  Jus  Talmud.  Cod.  Erivin.,  c.  2 ; 
Heidegg.  Hist.  Patriarch.,  i.  i.  128;  C.  'Qim\)mde  Monstrorii,mNaturd,Qt(i.,Yih.  i.  c. 
24  ; and  Arnaud’s  Memoire,  p.  249.)  It  is  further  interesting  to  remark  that 
Plato,  in  his  Symposion,  introduces  Aristophanes  as  holding  the  same  opinion. 
“ The  ancient  nature,”  he  observes,  “of  men,  was  not  as  it  now  is,  but  very  differ- 
ent ; for  then  he  Avas  androgynous  both  in  form  and  name  {afdpoyvvov  kui  etSos  Kai 
ovoya.)”  Probably  from  the  licentious  purposes  alluded  to  by  Justin  Martyr,  or 
from  the  Aveak  and  imbecile  character  of  hermaphrodite  individuals,  the  word 
avdpoyvvos  came  in  latter  times  to  signify  effeminate  and  luxurious.  The  ancient 
Icxicograplier  Hesychius  gives  it  this  meaning  ; and  Tlieodoret,  in  his  Therap., 
speaks  of  Bacchus  as  being  licentious,  effeminate,  and  androgynous — {yvvpis  wr,  kui 
OyXvbpLas,  /cat  avbpoyvvos). 

^ Home’s  Comp.  Anat.  vol.  iii.  p.  317.  On  the  peculiarities  of  the  external 
genital  organs  in  A^arious  African  tribes,  see  a learned  paper  by  Prof.  Muller  in  his 
Archiv  fiir  Anatomic  for  1834,  Heft  iv.  s.  319,  Avith  ample  referenees  to  the' 
observations  and  opinions  of  Levaillant,  Barrow,  Peron,  Lesner,  Lichtenstein, 
Burchell,  Somerville,  etc.  See  also  Otto,  in  his  Ncue  Seltene  Beobachtungen  zur 
Anatomic,  p.  135,  shoAving  the  very  prominent  external  female  parts  of  different 
African  tribes  to  consist  differently — 1.  of  enlarged  nymplue,  2.  of  enlarged  labia, 
and  3.  of  the  enlarged  clitoris. 

- El.  Phys.  tom.  vii.  part  ii.  pp,  81-2. 

3 Dissertation  sur  les  Hermaphrodites,  p.  372.  See  also  Homberg,  De  Excres- 
centid  Clitoridis  nimid,  Jena,  1671;  Txonchiu,  Dc  Clitoride,  Lugd.  1736;  and 
Ploucquet’s  Literatura  Mrdicd,  art.  “Clitoris  l^tagna,”  tom.  i.  ]>.  299. 


SPURIOUS  IN  FEMALES. 


413 


forated  by  the  urethra,  and  its  wanting  the  corpus  spongiosum — a 
peculiarity  of  defect  of  structure  that  exists  as  the  natural  type  of 
formation  in  the  penis  of  male  reptiles.  In  the  human  subject, 
tlie  organs  are  composed  internally  of  the  same  kind  of  erectile 
tissue,  and  when  we  descend  in  the  animal  scale,  and  examine  their 
relations  in  the  male  and  female  of  the  same  species,  we  find  some 
still  more  striking  analogical  peculiarities  of  structure.  Thus,  in 
several  of  the  Carnivora  and  Itodentia,  as  in  the  lioness,  cat,  raccoon, 
bear,  marmot,  etc.,  the  clitoris  contains  a small  bone  like  that  be- 
longing to  the  penis  of  the  male  of  the  same  species  ; and  amongst 
the  Monotremata  and  Marsupiata,  the  clitoris  of  the  female,  like  the 
penis  of  the  male,  is  surmounted  by  a bifid  glans.  In  a species  of 
lemur  {Loris  gracilis  or  Stenops  tardigradus)  the  clitoris  is  of  a very 
large  size  ; and  the  urethra,  as  first  pointed  out  by  Daubenton,‘  runs 
forward  and  opens  at  its  anterior  extremity  between  the  branches 
of  its  glans,  imitating,  in  this  point  of  structure,  the  penis  of  the 
male  among  the  Mammalia. 

In  the  human  subject  the  mere  enlargement  of  the  clitoris  alone 
has  seldom  of  itself  given  rise  to  errors  with  regard  to  the  sex  of 
the  individual,  except  in  young  children  ; but  it  has  frequently  hap- 
pened that  along  with  it  other  minor  malformations  have  co-existed, 
so  as  to  render  the  sexual  distinction  much  more  ambiguous.  In 
women  possessing  this  peculiarity  of  structure  we  sometimes  ob- 
serve, for  instance,  the  clitoris  not  only  resembling  the  penis  in  size, 
but  it  has  an  indentation  at  the  point  of  the  glans,  imitating  the 
orifice  of  the  urethra  ; and  occasionally  the  glans  is  actually  per- 
forated to  a certain  extent  backwards,  or  the  body  of  the  clitoris  is 
drilled  more  or  less  imperfectly  with  a canal  like  that  of  the  male 
urethra.  In  other  instances  the  canal  and  orifice  of  the  female 
vagina  are,  by  an  excess  of  development  in  the  median  line  of  the 
body,  much  contracted  or  nearly  shut  up,  the  vulva  being  closed  by 
a strong  membrane  or  hymen,  and  the  labia  cohering,  so  as  to  give 
the  parts  a near  resemblance  to  the  united  or  closed  perineum  and 
scrotum  of  the  male.  Further,  in  one  or  two  very  rare  cases  which 
have  been  put  uj^on  record,  the  ovaries  and  Fallopian  tubes  seem 
to  have  descended  through  the  inguinal  rings  into  the  labia,  thus 
giving  an  appearance  of  the  presence  of  testicles ; and  a fallacy 
seems  to  have  occurred  in  some  cases  from  the  presence  of  roundish 
m.asses  of  fat  in  this  situation,  simulating  more  or  less  the  same 
male  organs. 

^ Audibert,  Histoirc  Nat.  des  Singes,  tab.  ii.  fig.  8. 


414 


HERMAPHEODITISM. 


Besides,  it  often  happens  in  those  women  who  present  more  or 
fewer  of  these  peculiarities  of  conformation  in  the  external  genital 
parts,  that  the  general  or  secondary  sexual  characters  of  the  female 
are  wanting,  or  developed  in  a slighter  degree  than  natural,  owing 

probably  to  the  malformations  of 
the  external  organs  being  often 
combined  with  some  co-existing 
anomalies  in  those  more  import- 
ant internal  reproductive  organs, 
the  healthy  structure  and  action 
of  which  at  the  time  of  puberty 
appear  to  exercise  so  great  an  in- 
fluence on  the  development  of  the 
peculiar  general  conformation  and 
moral  character  of  the  female. 
Thus  the  features  are  sometimes 
hard,  the  figure  and  gait  rather 
masculine,  the  mammae  slightly 
developed,  the  voice  is  deep  toned, 
and  the  chin  and  upper  lip  are  occasionally  covered  with  a quantity 
of  hair.  In  fact,  in  some  marked  cases  the  whole  external  character 
approaches  to  that  of  the  male,  or,  more  properly  speaking,  occupies 
a kind  of  neutral  ground  between  that  of  the  two  sexes.  Some 
of  the  more  striking  examples  of  this  first  variety  of  spurious  her- 
maphroditism in  the  female  will  sufficiently  illustrate  the  above 
remarks. 

Dr.  Eamsbotham^  has  briefly  described  the  genital  parts  of  an 
infant,  that  was  christened  and  looked  upon  as  a boy,  until  dissec- 
tion after  death  showed  that  the  sex  was  actually  female.  The  uterus 
and  other  female  organs  (Fig.  1,  cc)  were  present  and  apparently 
naturally  formed ; but  the  clitoris,  h,  was  fully  as  large  as,  and  in 
appearance  closely  resembled,  the  penis  of  a male  of  the  same  age. 
At  its  anterior  extremity  there  was  a sulcus,  ft,  which  was  not  the 
entrance  of  the  urethra,  but  terminated  in  a cul-de-sac.“ 

1 Medical  Gazette,  xiii.  p.  184. 

2 In  Guy's  Hospital  Reports  for  1840,  p.  243,  there  are  a succinct  account  and 
excellent  drawings  of  a case  of  this  variety  of  spurious  hermaphroditism.  The 
subject  was  an  adult.  The  ovaries  were  small  ; but  the  Fallopian  tubes  and  uterus 
were  otherwise  normal.  The  vagina,  about  three  inches  long,  entered  inferiorly 
into  the  canal  of  the  urethra.  About  an  inch  after  this  junction  the  urethra 
opened  externally,  as  in  the  female  ; but  there  was  no  vulva.  The  labia  externa 
were  united  together,  so  as  to  represent  a scrotum,  and  projected  on  each  side  as 


Fio:.  1. 


SPURIOUS  m FEMALES. 


415 


Columbus  ‘ and  De  Graaf  ^ give  two  similar  examples  of  the  same 
form  of  spurious  hermaphroditism  in  young  children,  in  which  the 
true  sex  was  only  fully  ascertained  by  dissection  after  death.  In 
relation  to  the  clitoris  in  the  case  described  by  Columbus,  that 
author  states  that  this  organ  was  furnished  with  two  muscles  only, 
and  not  with  four,  as  in  the  perfect  female. 

Ill  a reputed  hermaphrodite  woman,  Gnllay^  found  after  death 
the  clitoris  to  be  three  and  a half  inches  long,  and  three  inches  and 
four  lines  in  circumference.  The  glans  and  prepuce  ivere  well  de- 
veloped. The  urethra  ran  as  in  man  through  the  body  of  the  penis 
and  its  glans.  The  labia,  nymphie,  vagina,  etc.,  were  natural,  and 
the  internal  female  organs,  the  ovaries.  Fallopian  tubes,  and  uterus, 
are  described  as  scirrhous.  This  Avoman  had  been  married,  but  never 
had  any  children  ; her  catamenia,  however,  had  been  very  regular. 
She  had  a considerable  quantity  of  hair  upon  her  face,  and  her  A^oice 
was  harsh  and  masculine. 

In  a child,  tAvo  years  of  age,  Schneider,'*  on  dissection  after  death, 
could  find  neither  the  labia  externa  nor  interna,  nor  any  trace  of  the 
ordinary  cleft  between  them.  The  clitoris  Avas  an  inch  and  a half 
long,  and  externally  resembled  most  perfectly  a male  penis  furnished 
Avith  a glans  and  prepuce  ; but  it  Avas  imperforate,  having  only  at  its 
anterior  extremity  a small  spot  marking  the  situation  of  the  open- 
ing of  the  urethra  in  the  male.  Some  lines  beloAv  there  Avas  an 
opening  by  Avhich  the  urine  Avas  evacuated.  This  opening  formed 
the  entrance  to  the  vagina,  which  AA^as  found  of  the  usual  length, 
and  Avith  the  characteristic  rugae.  The  canal  of  the  urethra  Avas 
found  entering  its  roof,  but  in  such  a manner  that  the  urine  AA^as 
ahvays  evacuated  very  sloAvly  and  by  drops  only,  from  the  external 
opening.  All  the  internal  female  sexual  organs  Avere  natural. 

M.  Bedard^  has  left  us  a very  detailed  and  interesting  descrip- 
tion of  an  example  of  spurious  hermaphroditism  referable  to  the  pre- 
sent Amriety,  and  exhibited  at  Paris  in  1814.  The  subject  of  the 

if  they  contained  testes  ; on  dissection,  hoAvever,  these  projections  Avere  found 
merely  masses  of  fat.  The  clitoris  Avas  elongated  to  tAA'o  inches,  and  proportion- 
ately increased  in  thickness  ; its  glans  AA’as  large.  The  case  is  described  by  Sir 
Astley  Cooper.  Another  analogous  instance  Avith  an  autopsy  is  giA^eu  by  Dr. 
Neill  in  the  Avicrican  Journal  of  Medical  Science  for  1851,  p.  558.  All  the 
internal  organs  Avere  female  ; the  representative  penis  Avas  five  inches  long  ; the 
urogenital  opening  at  its  root  Avas  very  small.  ^ De  Be  Anatoniicd,  lib.  xv.  p.  493. 

2 OjJ.  Oni.  cap.  iii.  xv.,  or  De  muUcruni  organis  gen.  inserv.,  Avith  a plate. 

3 Arnaud,  1.  c.  p.  309.  ^ Jahrbucher  der  Staatsarzneilcunde^  1809,  s.  193. 

® BuUctin  de  la  Facidte  for  1815,  p.  273. 


416 


HERMAPHRODITISM. 


case,  Marie  Madeline  Lefort,  was  at  that  time  sixteen  years  of  age. 
The  proportions  of  the  trunk  and  members,  and  of  the  shoulders 
and  pelvis,  and  the  conformation  and  dimensions  of  this  last  part  of 
the  body,  were  all  masculine ; the  volume  of  the  larynx  also,  and 
the  tone  of  the  voice,  were  those  of  an  adolescent  male ; a beard 
was  appearing  on  the  upper  lip,  chin,  and  region  of  the  parotids ; 
some  hairs  were  growing  in  the  areola  around  the  nipple  ; and  the 
mammae  were  of  a moderate  size.  The  inferior  extremities  were 
furnished  with  an  abundance  of  long  hard  hairs.  The  symphysis 
pubis  was  elongated  as  in  man ; the  mons  veneris  rounded,  and  the 
labia  externa  were  covered  with  hair.  The  clitoris  was  10  J (?) 
inches  (27  centimetres)  in  length  when  at  rest,  but  somewhat  more 
when  erect ; its  glans  was  imperforate,  and  covered,  in  three-fourths 
of  its  circumference,  with  a mobile  jDrepuce.  The  body  of  this  en- 
larged clitoris  was  furnished  inferiorly  with  an  imperfect  canal,  which 
produced  a depression  in  it,  instead  of  that  prominence  of  this  part 
which  exists  in  the  male  penis.  This  canal  was  pierced  along  its 
under  surface  and  median  line  by  five  small  holes  capable  of  admit- 
ting a small  stylet ; and  one  or  more  similar  apertures  seemed  to 
exist  in  it  after  it  passed  backwards  within  the  vagina.  The  labia 
were  narrow  and  sliort,  and  the  vulva  or  sulcus  between  them  was 
superficial,  being  blocked  up  by  a dense  membrane,  which,  under 
the  pressure  of  tlie  finger,  felt  as  if  stretched  towards  the  anus  over 
a cavity.  At  its  anterior  part,  or  below  the  clitoris,  there  was  an 
opening  capable  of  admitting  a sound  of  moderate  size,  and  this 
sound  could  be  made  to  pass  backwards  behind  the  membrane  clos- 
ing the  vulva,  which,  when  felt  between  the  point  of  the  instrument 
and  the  finger,  seemed  about  twice  as  thick  as  the  skin.  The  urine 
was  passed  by  this  opening,  and  also,  according  to  the  report  of  the 
individual  herself,  through  the  cribriform  holes  in  the  canal  extend- 
ing along  the  inferior  surfiice  of  the  urethra.  By  the  same  opening 
the  menstrual  fluid  escaped,  as  Bedard  ascertained  on  one  occasion 
by  personal  examination.  She  had  menstruated  regularly  from  the 
age  of  eight  years,  considered  herself  a female,  and  j)referred  the 
societ}^  of  men. 

In  this  interesting  case,  we  have  present  all  the  secondary  sexual 
characters  of  the  male,  with  some  of  the  female  genital  organs  de- 
veloped in  so  excessive  a degree  as  to  approach  in  several  points 
their  more  perfect  structure  in  man.  The  impossibility,  however,  as 
mentioned  by  Bedard,  of  finding  any  bodies  like  testicles  in  the  labia 
or  in  the  course  of  the  inguinal  canals,  and  more  particularly  the 


SPURIOUS  IN  FEMALES. 


417 


well-ascertained  fact  of  the  individual  menstruating,  can  leave  no 
doubt  as  to  the  nature  of  her  sex.  The  perforation  of  the  enlarged 
clitoris  by  the  imperfect  urethra  is  interesting,  when  compared  with 
the  peculiarities  that  we  have  formerly  alluded  to,  of  this  part  in 
the  female  Loris,  as  pointing  out 
— what  we  have  so  often  occasion 
to  observe  in  human  monstrosities 
— a type  of  structure  assumed  by 
a malformed  organ  similar  to  the 
normal  type  of  structure  of  the  same 
organ  in  some  of  the  inferior  animals. 

Arnaud^  has  represented  and 
described  at  great  length  an  interest- 
ing example  of  hermaphroditic  mal- 
formation that  seems  referable  to 
the  head  of  spurious  hermaphrodit- 
ism in  the  fern  ale,  although  there  are 
two  circumstances  in  the  history  of  the  case  which  have  led  some 
authors  to  doubt  the  accuracy  of  this  opinion ; and  the  opportunity  that 
was  afforded  of  ascertaining  the  true  structure  of  the  parts  after  death 
was  unfortunately  lost  through  carelessness  and  neglect.  The  subject 
of  the  malformation,  aged  35,  passed  in  society  for  a female,  and 
came  to  Arnaud  complaining  cf  a small  tumour  (Fig.  2,  e)  in  the 
right  groin,  which  had  much  incommoded  her  during  her  whole  life. 
On  examining  this  body,  Arnaud  was  led  to  believe  that  it  was  a 
testicle,  and  he  found  a similar  tumour,  /,  situated  nearer  the  in- 
guinal ring  on  the  left  side.  The-  bags  that  contained  them  repre- 
sented very  exactly  the  labia  externa.  The  clitoris,  a,  was  two 
inches  and  nine  lines  in  length,  and  placed  between  the  labia  at  their 
upper  angle.  The  glans,  h,  was  well  formed,  and,  though  imperforate 
at  its  extremitj'’,  it  presented  a small  depression  which  ran  backwards 
along  the  whole  inferior  border  of  the  clitoris,  indicating  the  situation 
of  a collapsed  urethral  canal,  that  seemed  pervious  for  some  length 
at  its  posterior  part,  as  it  became  distended  when  the  patient  evacu- 
ated the  bladder.  The  orifice,  c,  however,  from  which  the  urine 
actually  flowed,  occupied  the  situation  in  which  it  exists  in  the 
perfectly  formed  female.  There  was  not  any  vaginal  opening,  and 
the  individual  menstruated  per  anum.  At  each  menstrual  period 
a tumour,  d,  always  appeared  in  the  perineum,  which  gradually 
increased  in  size,  becoming  in  the  course  of  three  or  four  days  as 
^ Dissertation  sur  les  Hermaphrodites,  p.  265,  pi.  x. 


418 


HERMAPHRODITISM. 


large  as  a small  lien’s  egg.  When  the  perineal  tumour  had  reached 
this  size,  blood  began  to  flow  from  the  anus,  although  no  hemor- 
^ rhoids  or  other  disease  of  the  bowel  was  present.  At  these  periods 
the  individual  had  often  experienced  very  alarming  symptoms,  and 
in  order  to  avert  these,  Arnaud  was  induced  to  make  an  opening 
into  the  soft  yielding  space  at  which  the  perineal  tumour  above 
alluded  to  appeared ; and  at  a considerable  depth  he  found  a cavity 
two  inches  in  circumference,  and  about  two  and  a half  in  breadth, 
having  projecting  into  it  at  one  point  an  eminence  which  was  sup- 
posed from  its  situation  to  be  possibly  the  os  uteri.  At  the  next 
period  the  menstrual  fluid  came  entirely  by  the  artificial  perineal 
opening,  and  the  usual  severe  attendant  symptoms  did  not  supervene. 
From  inattention,  however,  to  the  use  of  the  tent,  the  opening  was 
allowed  to  become  completely  shut,  so  that  at  the  sixth  return  of 
the  menses  they  flowed  again  by  the  anus,  and  were  accompanied 
by  the  old  train  of  severe  symptoms.  The  individual  lived  for 
several  years  afterwards.  Her  conformation  of  body  was  remark- 
able. Her  skin  was  rough,  thick,  and  swarthy;  she  had  a soft  black 
beard  on  her  face;  her  voice  was  course  and  masculine;  her  chest 
narrow;  her  mammae  were  flat  and  small;  her  arms  lean  and 
muscular;  her  hands  large,  and  her  fingers  of  very  considerable 
length  and  strength.  The  form,  in  fact,  of  the  upper  part  of  her 
body  was  masculine,  but  in  the  lower  part  the  female  conformation 
predominated.  The  pelvis  was  wide  and  large,  the  os  pubis  very 
elevated,  the  buttocks  large,  the  thighs  and  legs  round,  and  the  feet 
small. 

In  this  remarkable  instance,  if  we  do  not  go  so  far  as  to  con- 
ceive the  co-existence  of  some  of  the  internal  organs  of  both  sexes, 
we  must,  from  the  well-ascertained  fact  of  the  menstrual  evacuations, 
allow  the  person  at  least  to  have  been  a female.  In  that  case  we 
can  only  suppose  the  tumours  in  the  labia  to  be  the  ovaries 
descended  in  that  situation  ; and  to  the  same  excess  of  development 
which  had  produced  this  effect,  we  may  attribute  the  closure  of  the 
vaginal  orifice,  and  the  formation  of  the  imperfect  urethral  canal  in 
the  body  of  the  clitoris. 

Spurious  hermaphroditism  from  preternatural  enlargement  of  the 
clitoris  has  been  recognised  among  some  of  the  lower  animals. 
Kudolphi  - has  noticed  a mare  of  this  kind  that  had  a clitoris  so 

^ Beinerlcunrien  auf  cincr  Reise,  Bd.  i.  s.  79.  See  also  a case  figured  by 
Ruysch  in  his  Thesaurus  Anal.  lib.  viii.  No.  53. 


SPURIOUS  IN  FEMALES. 


419 


large  as  almost  to  shut  up  the  entrance  into  the  vagina.  Lecoqi 
has  detailed  the  case  of  a calf  which  Gurlt  ^ believes  to  belong  to 
the  present  head.  Neither  testicles  nor  scrotum  were  observed 
externally,  and  the  penis  or  enlarged  clitoris,  which  occupied  its 
normal  situation,  was  apparently  perforated  by  the  urethra,  and 
crooked  upwards  so  as  to  throw  the  urine  in  that  direction.  Mery  ^ 
showed  by  dissection  the  true  sex  of  a monkey,  the  length  of  whose 
clitoris  had  deceived  some  observers  with  regard  to  the  true  sex  of 
the  animal.  The  enlarged  clitoris  was  furrowed  on  its  inferior 
surface.  The  clitoris  of  the  female  Quadrumana  is,  as  will  after- 
wards be  more  particularly  mentioned,  relatively  larger  than  in  the 
human  subject,  and  retains  in  a greater  degree  the  size  and  type  of 
structure  of  this  organ  in  the  embryo. 

We  may  here  further  mention  that,  as  pointed  out  by  Blumen- 
bach,^  the  clitoris  and  orifice  of  the  urethra  are  placed  at  some 
distance  from  the  vagina  and  in  front  of  it,  in  the  rat,  mouse, 
hamster,  etc.  This  normal  structure  has  sometimes  been  mistaken 
for  a hermaphroditic  malformation. 

2.  Frolajmis  of  the  Uterus. — It  m.ay  at  first  appear  strange  that 
this  occurrence  should  ever  lead  to  any  difficulty  in  ascertaining  the 
sex  of  the  individual,  though  not  only  non-professional  observers, 
but  even  the  most  intelligent  medical  men,  have  occasionally  been  so 
far  misled  by  the  similarity  of  the  protruded  organ  to  the  male 
penis,  as  to  mistake  a female  for  a male.  Of  this  circumstance  some 
curious  illustrations  are  on  record.® 

M.  Veay,  physician  at  Toulouse,  has  inserted  in  the  Philosopliko.l 
Transactions  of  London/  a brief  account  of  the  case  of  Marguerite 
Malause  or  Malaure,  who  was  entered  as  a female  patient  in  the 
Toulouse  Hospital  in  1686.  Her  trunk,  face,  etc.,  presented  the 
general  configuration  of  a female,  but  in  the  situation  of  the  vulva 
there  was  a body  eight  inches  in  length  when  on  its  fullest  stretch, 
and  resembling  a perfectly  formed  male  penis  in  all  respects,  excej^t 
in  not  being  provided  with  a prepuce.  Through  the  canal  perforat- 
ing this  body  she  was  alleged  to  evacuate  her  urine,  and  from  its 
orifice  M.  Yeay  had  himself  an  opportunity  of  seeing  the  menstrual 
fluid  flow.  After  being  examined  by  several  physicians,  she  was 

^ Journ.  Prat.  c7e  Mkl.  VH.  1827,  p.  103. 

2 Lchrhuch  dcr.  Pathol.  Anat.  Bd.  ii.  s.  193. 

^ Hist,  dc  V Acad.  1686,  tom.  i.  j).  345.  * Comp.  Anat.  p.  335. 

® Doebel,  in  Nov.  Liter.  Maris  P>althici,  1698,  p.  238. 

® Phil.  Trans,  vol.  xvi.  p.  282. 


420 


HERMAPHRODITISM. 


pronounced  to  be  more  male  than  female,  and  ordered  by  the  civil 
authorities  to  exchange  the  name  of  Marguerite  for  that  of  Arnaud, 
and  to  wear  male  attire.  In  1693  she  visited  Paris  in  her  male 
habiliments,  and  reputed  herself  endowed  with  the  powers  of  both 
sexes.  The  Parisian  physicians  and  surgeons  who  examined  her 
seem  all  to  have  accorded  in  opinion  with  the  faculty  of  Toulouse, 
until  M.  Saviard  ^ saw  her,  and  detected  the  supposed  penis  to  be 
merely  the  prolapsed  uterus.  He  reduced  the  protruded  organ,  and 
cured  the  patient.  Upon  the  enigma  of  her  hermaphroditism  being 
thus  solved,  she  was  permitted  by  the  king,  at  her  own  request,  to 
assume  again  her  female  name  and  dress. 

Sir  E.  Home^  detected  a case  of  reputed  hermaphroditism,  of 
the  same  description  as  the  last,  in  a French  woman,  twenty-five 
years  of  age,  who  exhibited  herself  in  London,  and  pretended  to 
have  the  powers  of  a male.  The  cervix  uteri  was  uncommonly 
narrow,  and  projected  several  inches  beyond  the  external  opening 
of  the  vagina.  The  everted  mucous  surface  of  the  vagina  had,  from 
constant  exposure,  lost  its  natural  appearance,  and  resembled  the 
external  skin  of  the  penis.  The  orifice  of  the  os  tincse  had  been 
mistaken  for  the  orifice  of  the  urethra.  The  prolapsus  had  been 
observed  at  an  early  age,  and  had  increased  as  the  woman  grew  up. 

Valentin^  mentions  another  analogous  instance  of  sexual  ambi- 
guity produced  by  a prolapsus  of  the  uterus.  In  this  case  the 
husband  mistook  the  displaced  organ  for  the  penis,  and  accused  his 
wife  of  having  “ cum  sexu  virili  necquicquam  commune.” 

A case  quoted  at  great  length  by  Arnaud  * from  Duval,  of  re- 
puted hermaphroditism  in  a person  that  was  brought  up  as  a woman, 
and  married  at  twenty-one  years  of  age  as  a male,  but  who  was 
shortly  afterwards  divorced  and  imprisoned,  and  ordered  again  by 
the  Court  of  Eouen  to  assume  the  dress  of  a woman,  appears  to  us 
to  belong  very  probably  to  the  present  division  of  our  subject,  the 
reputed  penis  being  described  as  placed  within  the  vagina.  The  re- 
corded details  of  the  case,  however,  are  not  so  precise  as  to  leave  us 
without  doubt  in  regard  to  its  real  nature. 

In  cases  such  as  those  now  mentioned,  in  which  the  prolapsed 
uterus,  or,  more  properly  speaking,  the  prolapsed  uterus  and  va- 
gina, have  been  mistaken  for  the  penis,  it  appears  probable  that 

^ Recueil  cC Observations  Chirurgicales,  p.  150.  ^ Comp.  Anat.  vol.  iii.  p.  318. 

^ Pandectce  Medico-Legales,  tom.  i.  p.  38,  Casus  xii. 

^ Mem.  sur  les  Hermaplir.  pp.  314-18. 


SPUEIOUS  IN  MALES. 


421 


the  neck  of  the  uterus  must  have  been  preternaturally  long  and 
narrow,  otherwise  it  would  be  difficult  to  account  for  the  apparent 
small  diameter  and  great  length  of  the  prolapsed  organ.  In  Pro- 
fessor Thomson’s  collection  of  drawings  of  diseased  anatomical 
structures,  there  is  one  of  a uterus  containing  in  its  body  a fibro- 
calcareous  tumour,  and  having  a neck  three  inches  in  length.  M. 
Cruveilhier  ^ has  represented  a similarly  diseased  uterus  with  a neck 
of  between  five  and  six  inches.  An  organ  shaped  in  this  manner, 
Avhether  from  congenital  malformation  or  acquired  disease,  would, 
when  prolapsed  for  some  time,  represent,  we  conceive,  a body  re- 
sembling in  form  and  size  those  observed  in  Saviard’s  and  Home’s 
cases.*  The  prolapsus  arising  from  the  protrusion  of  an  ordinarily 
shaped  uterus  is  generally  of  a greater  diameter  and  roundness. 

This  second  species  of  spurious  female  hermaphroditism  is  not 
observed  among  the  lower  animals. 

B.  Spurious  Hermaphroditism  in  the  Male. 

Malformed  males  have  more  often  been  mistaken  for  females 
than  the  reverse.  The  varieties  of  malformation  in  persons  actually 
male,  that  are  liable  to  lead  to  mistakes  with  regard  to  their  true 
sex,  appear  to  be — 1st,  Extrophy  or  extroversion  of  the  urinary 
bladder ; 2d,  Adhesion  of  the  inferior  surface  of  the  penis  to  the 
scrotum  ; and  3d,  and  principally.  Fissure  of  the  inferior  part  of  the 
urethra  and  of  the  scrotum  and  perineum. 

1.  Extroversion  of  the  urinary  bladder. — For  a full  description  of 
this  malformation,  we  must  refer  elsewhere.^  This  malformation  is 
known  to  occur  more  frequently  in  the  male  than  in  the  female,  and 
when  present  in  the  former,  it  has  occasionally  given  rise  to  a sup- 
position of  hermaphroditism,  the  red  fungous  mass  formed  by  the 
mucous  membrane  of  the  protruded  posterior  wall  of  the  bladder 
and  situated  above  the  pubis,  having  been  mistaken  for  the  female 
vulva.  This  error  has  probably  been  the  more  readily  committed, 
from  the  uterus  and  seminal  ducts,  and  sometimes  also — as  in  an 
instance  described  by  A.  FraenkeT — a part  of  the  intestinal  canal, 

^ Anat.  Pathol,  liv.  xiii.  pi.  iv. 

2 Some  years  ago  there  was  a case  of  longitudinal  hypertrophy  of  the  cervix 
uteri  in  the  Edinburgh  Infirmary,  where  the  prolapsed  and  elongated  cervix  uteri 
very  exactly  resembled  a male  penis. 

^ Cyclop,  of  Anat.  and  Phys.,  articles  “Bladder,  and  Monstrosity.” 

^ Dc  Organorum  Generationis  Deform.,  rarissinid,  Berlin,  1825,  with  a plate. 


422 


HERMAPHRODITISM. 


opening  upon  the  surface  of  the  exposed  portion  of  bladder.  In 
some  instances  of  this  malformation  occurring  in  man,  the  external 
male  sexual  organs  are  very  imperfectly  formed,  or  can  scarcely  be 
said  to  be  at  all  present.  In  other  cases  the  scrotum  is  of  the 
natural  form,  with  the  two  testicles  in  it ; and  the  penis  is  of  con- 
siderable size,  though  almost  always  fissured  on  its  upper  surface 
from  the  epispadiac  or  open  state  of  the  urethra. 

An  example  of  supposed  hermaphroditic  malformation,  briefly 
described  by  Eueffe,^  which  seems  referable  to  this  variety,  will  be 
sufficient  to  illustrate  it.  “In  the  year  1^19,  a hermaphrodite  or 
androgynus,”  he  remarks,  “ was  born  at  Zurich,  perfectly  formed 
from  the  umbilicus  upwards,  but  having  at  this  part  a red  mass  of 
ffesh,  beneath  which  were  the  female  genitals,  and  also  under  and  in 
their  normal  situation  those  of  the  male.” 

2.  Adhesion  of  the  inferior  surface  of  the  loenis  to  the  scrotum  hy  a 
hand  of  integument. — This  state  of  the  parts  has  occasionally  given 
rise  to  the  idea  of  hermaphroditism,  the  penis  being  so  bound  down 
as  not  to  admit  of  erection,  and  the  urine  passing  in  a direction 
downwards,  so  as  to  imitate  the  flow  of  it  in  the  female. 

In  a boy,  seven  years  of  age,  regarding  whom  Brand  ^ was  con- 
sulted, the  penis  was  confined  in  this  manner  to  the  scrotum  by 
abnormal  adhesions.  He  had  been  baptized  and  reared  as  a girl, 
but  by  a slight  incision  the  adherent  organ  was  liberated,  and  the 
parents  were  convinced  of  the  mistake  that  they  had  committed  in 
regard  to  the  sex  of  their  child.  The  difficulty  of  determining  the 
true  sex  of  the  boy  was  increased  by  the  testicles  not  having  de- 
scended into  the  scrotum. 

Wrisberg^  mentions  two  similar  instances,  in  persons  of  the 
respective  ages  of  nineteen  and  forty-six.  He  relieved  the  adherent 
penis  in  the  first  case  by  operation. 

3.  Fissure  of  the  inferior  part  of  the  urethra,  perineum,  etc.  — 
Hypospadias. ^ — This  species  of  malformation,  which  has,  perhaps, 
more  frequently  than  any  other  given  rise  to  the  idea  of  the  person 
affected  with  it  being  the  subject  of  hermaphroditism,  evidently 
consists  in  an  arrest  of  the  development  of  the  external  male  sexual 
parts. 

At  an  early  stage  of  the  development  of  the  embryo,  the  various 

^ Be  Conceptu  et  Generatione  Hominis,  p.  44. 

* Case  of  a boy  who  had  been  mistaken  for  a girl  : London,  1788. 

3 Comment.  Med.,  etc.,  p.  534. 


HYPOSPADIAS. 


423 


central  sexual  organs  are,  like  all  the  other  single  organs  situated  in 
the  median  line  of  the  body,  found  to  be  composed  of  two  separate 
and  similar  halves,  divided  from  each  other  by  a vertical  fissure, 
which,  after  the  originally  blind  extremity  of  the  intestinal  canal  has 
opened  upon  the  perineum,  forms  a common  aperture  or  cloaca  for 
the  intestinal  canal,  and  also  for  the  urinary  and  genital  apparatus, 
both  of  which  are,  in  their  primary  origin,  prolongations  from  the 
lower  part  of  that  canal.  After  a time  (about  the  second  month  in 
the  human  embryo),  the  opposite  sides  of  this  cloaca  gradually  ap- 
proximate, and  throw  out  two  corresponding  folds,  which  by  their 
union  constitute  a septum  that  separates  the  rectum  from  the  canal, 
or  portion  of  the  fissure,  that  still  remains  common  to  the  urinary 
and  generative  organs ; and,  in  the  same  way,  by  two  similar  and 
more  anterior  folds,  the  urethra  of  the  female,  and  the  pelvic  por- 
tion of  that  of  the  male,  is  subsequently  produced.  After  this,  in 
the  female  the  process  of  median  reunion  does  not  proceed  farther, 
and  the  primary  perineal  fissure  remains,  forming  the  vulva  and 
vagina.  In  the  male,  however,  the  development,  when  normal,  goes 
on  to  a greater  extent,  and  the  sides  of  the  opening  become  so  far 
united  as  ultimately  to  leave  only  the  comparatively  contracted 
canal  of  the  urethra  to  serve  as  a common  passage  for  both  the 
internal  urinary  and  genital  organs  ; and  the  situation  of  the  line  of 
junction  of  the  opposite  sides  of  the  original  perineal  cleft  remains 
still  marked  out  in  the  adult,  by  the  raphe  existing  in  the  median 
line  of  the  scrotum.  The  two  lateral  parts  of  the  female  clitoris 
unite  together  into  one  solid  body,  having  on  its  under  surface  a 
slight  groove  or  channel,  indicative  of  the  line  of  conjunction  of  its 
two  component  parts  ; and  the  urethra  is  left  to  open  at  the  root 
of  this  imperforated  organ.  In  the  male,  on  the  contrary,  the  two 
primitive  halves  of  the  penis,  consolidated  together  at  an  early  stage 
along  the  course  of  their  upper  surfaces,  come,  about  the  third 
month  of  development,  to  unite  interiorly  in  such  a manner  with 
one  another  as  to  form  a tubular  prolongation  of  the  pelvic  portion 
of  the  canal  of  the  urethra,  which  is  gradually  extended  forwards, 
first  along  the  body  of  the  penis,  and  ultimately  through  its  glans. 
In  the  earlier  periods  of  evolution,  the  prreputium  is  still  wanting ; 
but  as  the  penis  becomes  perforated,  the  pra3putium  grows  so  raj^idly, 
as  at  last  to  cover  and  inclose  the  glans. 

Many  of  the  malformations  to  which  the  male  genital  organs  are 
liable  may  be  traced  to  stoppages  in  the  above  process  of  develop- 
ment, the  character  of  the  malformation  depending  upon  the  period 
83 


424 


HERMAPHRODITISM. 


of  the  development  at  which  the  arrest  takes  place,  and  varying 
consequently  in  degree  from  the  existence  of  a cloaca  or  permanent 
primitive  fissure  common  to  the  intestinal,  urinary,  and  generative 
organs,!  to  that  want  of  closure,  to  a greater  or  less  extent  in  differ- 
ent instances,  of  the  inferior  surface  of  the  canal  of  the  urethra  in 
the  body  of  the  penis,  or  in  its  glans,  which  is  generally  known 
under  the  name  of  Hypospadias.  When  the  development  of  the 
male  organs  is  arrested,  immediately  after  the  two  septa  respectively 
separating  the  canals  of  the  intestine  and  urethra  from  the  original 
perineal  cleft  are  formed,  and  consequently  when  this  perineal  fis- 
sure and  that  running  along  the  inferior  surface  of  the  penis  are  still 
open,  the  external  genital  parts  often  come  to  present  at  birth,  and 
during  the  continuance  of  life,  a striking  resemblance  to  the  confor- 
mation of  the  external  organs  of  the  female,  and  the  resemblance  is 
frequently  rendered  greater  by  the  co-existence  of  other  malforma- 
tions of  the  male  organs.  In  these  cases  the  imperfect  and  unde- 
veloped penis  is  generally  of  small  size,  and,  at  the  same  time,  from 
being  imperforate,  may  readily  be  mistaken  for  the  clitoris  ; the  two 
halves  of  the  divided  scrotum  have  the  appearance  of  the  two  labia 
externa ; the  two  labia  interna  or  nymphse  are  som.etimes  repre- 
sented by  the  lateral  divisions  of  the  penis  forming  two  folds,  which 
run  backwards  along  the  internal  surfaces  of  the  split  scrotum  ; and 
the  cleft  in  the  perineum  corresponds  in  situation  and  direction,  and 
occasionally  also  in  size  and  form,  with  the  canal  of  the  vagina ; 
this  cleft  is  generally  lined  also  by  a red  mucous  membrane,  that  is 
kept,  like  the  natural  female  parts,  constantly  moistened  by  the 
secretions  of  the  follicles  with  which  it  is  provided ; its  mucous 
membrane  occasionally  presents  irregular  elevations,  imperfectly  re- 
presenting the  carunculse  myrtiformes  ; and,  further,  the  opening  of 
the  urethra  at  the  root  of  the  diminutive  and  imperforate  penis 
serves  still  more  to  assimilate  the  malformed  parts  to  the  natural 
conformation  of  the  female  organs.  In  a number  of  cases,  however, 
the  apparent  analogy  to  the  female  parts  is  rendered  less  striking 
by  the  perineal  cleft  being  small  or  altogether  absent,  the  urethral 
orifice  at  the  root  of  the  penis  often  forming  the  only  opening  lead- 
ing to  the  internal  urinary  and  generative  parts,  and  the  halves  of 
the  scrotum  in  such  instances  being  frequently  more  or  less  united. 
Generally,  the  seminal  ducts,  and  sometimes  also  the  ducts  of  Cow- 

! See  on  this  malformation  in  the  human  subject  (the  normal  form  of  structure- 
in  birds,  etc.),  Meckel  on  Kloakbihluug  in  his  Path.  Anat.  Bd.  i.  s.  693. 


' HYPOSPADIAS. 


425 


per’s  glands,  are  seen  opening  on  the  surhice  of  the  urethra  or  sup- 
posed vaginal  canal,  at  a short  distance  from  its  external  orifice.^ 

In  males  malformed  in  the  manner  described,  the  testicles  arc 
seldom  found  in  the  divided  scrotum  at  birth,  but  commonly  they 
descend  into  it  through  the  inguinal  rings  towards  the  period  of 
puberty ; and  in  several  instances  on  recoi’d,  in  which  the  sex  of  the 
individual  had  been  mistaken  for  that  of  a female,  the  tumours 
formed  in  the  groin  at  that  time  by  the  organs  in  their  descent,  have 
been  erroneously  regarded  and  treated  as  hernial  protrusions.  At 
the  same  time  it  occasionally  happens  that  with  the'  descent  of  the 
testicles,  and  the  arrival  of  puberty,  the  diminutive  penis  enlarges 
in  size,  and  the  individual  assumes  more  or  less  fully  the  habits  and 
attributes  of  the  male.  In  several  instances  on  record  this  change 
has,  under  venereal  excitation,  appeared  to  occur  suddenly,  and 
persons  formerly  reputed  female  have  thus  unexpectedly  found  them- 
selves provided  with  an  erectile  male  penis.  These  various  changes 
are  occasionally  postponed  for  a considerable  period  beyond  the 
usual  term  of  puberty. 

In  a few  rare  instances  one  testicle  only  descends  through  the 
inguinal  ring,  and  occasionally  they  both  remain  throughout  life 
within  the  abdomen,  in  or  near  the  situation  in  which  they  were 
originally  developed,  imitating  in  this  abnormal  state  the  normal 
position  of  the  same  organs  in  many  of  the  males  among  the  lower 
animals.  In  a number  of  instances  in  wliich  the  testicles  are  thus 
retained  within  the  cavity  of  the  abdomen,  they  are  found  small  and 
imperfectly  developed,  and,  from  the  want  of  their  usual  physiological 
influence  upon  the  constitution,  the  whole  physical  and  moral  cha- 
racter of  the  malformed  individual  frequently  presents  a considerable 
approximation  to  that  of  the  female,  or,  as  we  should  perhaps  more 
justly  express  it,  never  attains  the  perfection  of  the  male,  but  pre- 
serves that  kind  of  common  or  neutral  state  exhibited  by  the  consti- 
tution of  both  sexes  before  the  specific  sexual  characters  of  each  are 
developed  at  the  time  of  puberty. 

Numerous  curious  examples  of  mistakes  having  been  committed 
with  regard  to  the  sex  of  males  affected  with  the  above  species  of 
malformation  have  now  been  put  on  record,  from  the  time  at  which 
Iphis,  the  daughter  of  Ligdus,  King  of  Crete,  was  conceived  to  be 
changed  into  a man  by  the  miraculous  interference  of  Isis,  down  to 

^ In  the  well-known  case  of  Gottlieb  Gottlieb,  Mulder  used  a small  vaginal 
sycciilum  to  see  these  orifices,  and  obtained  seminal  fluid,  as  shown  by  the  micro- 
scope, from  the  orifices  of  the  vasa  deferentia. 


426 


HERMAPHRODITISM. 


the  present  day.  Pliny'  has  noticed  several  cases  ; and  in  the 
treatise  of  Duval  on  hermaphrodites,  a number  of  additional 
instances  are  collected  from  Livy,  Trallian,  and  others,  some  of 
them  no  doubt  invested  (as  most  of  the  details  regarding  herma- 
phrodites in  the  older  authors  are)  with  much  misrepresentation 
and  fable,  but  others  bearing  every  mark  of  accuracy  and  authenticity. 
In  more  modern  times  the  sexes  of  individuals  have  often  been 
mistaken  in  consequence  of  this  variety  of  malformation.  Jean 
Chroker^  relates,  in  apparently  the  most  authentic  manner,  the  case 
of  Magdelain  Mugnoz,  a nun  of  the  order  of  St.  Dominique,  in  the 
town  of  Ubeda,  who  was  changed,  as  he  supposes,  into  a male, 
seven  years  after  having  taken  the  vows.  He  was  expelled  the 
convent,  assumed  the  male  dress,  and  took  the  name  of  Fran9ois. 
The  sequel  of  the  story,  as  told  by  Chroker,  would  seem  to  show 
that  his  sexual  desires  became  extremely  strong,  and  he  is  said  to 
have  been  ultimately  condemned,  whether  justly  or  not,  under  an 
accusation  of  rape."^ 

Portal ' quotes  from  Tigeon  the  story  of  a person  who  was 
brought  up  as  a female,  and  afterwards  was  considered  to  be  suddenly 
changed  by  a surprising  metamorphosis  into  a male ; and  in  citing 
tins  case.  Dr.  Hodgkin®  of  London  mentions,  on  the  authority  of  a 
friend,  a recent  instance  of  an  equally  sudden  development  of  the 
male  sex  in  a previously  reputed  female.  Similar  instances,  in  which 
the  proper  sex  of  malformed  males  was  unexpectedly  discovered 
under  the  excitement  of  sexual  passion  at  the  period  of  puberty,  are 
mentioned  by  Pare,  Tulpius,  and  others. 

Schweikard®  has  recorded  an  instance  of  a person  baptized  and 
brought  up  as  a female,  and  whose  true  sex  was  only  at  last  disclosed 
by  his  requesting,  at  the  age  of  forty-nine,  permission  to  marry  a 
young  woman  then  pregnant  by  him.  On  examination,  it  was  dis- 
covered that  the  penis  was  slender,  and  scarcely  two  inches  long ; 
the  right  testicle  only  had  descended  into  the  scrotum,  and  the 

^ Lib.  vii.  cliap.  iv. 

- Fax.  Ilistor.  cent.  i.  ; and  Arnaud,  Dissertation  sur  Ics  Hermaphrodites, 

p.  200. 

2 After  this  essay  was  first  published  in  1839,  I received,  through  Dr.  Cowan, 
a long  account  and  drawings  of  a similar  case,  where  a child  taken  into  a convent 
in  Malta  as  a female  turned  out  at  puberty  to  be  an  amorous  hypospadiac  male  ; 
and  subseipiently  became  a sailor  instead  of  a nun.  I have  in  practice  been 
consulted  in  three  cases  where  hypospadiac  male  children  have  been  baptized  as 
gills.  Hist,  de  I'ylnat.  tom.  ii.  p.  52. 

Catalogue  of  Guy's  Hosintal  Museum,  part  ii.  sect.  11. 

® Ilufeland’s  Journal  der  Prak.  Heilkunde,  I3d.  xvii.  No.  18. 


HYPOSPADIAS. 


427 


urethra  opened  at  the  root  of  the  penis,  but  its  orifice  was  placed  in 
such  a manner  that  during  micturition  the  urine  was  thrown  along 
the  groove  or  channel  on  the  under  surface  of  the  penis,  so  as  to 
appear  to  issue  from  its  anterior  extremity.  The  two  halves  of  tlie 
scrotum  were  so  far  united  that  they  left  only  a small  oval  opening 
betvv^een  the  anterior  part  of  the  raphe  and  the  roots  of  the  corpora 
cavernosa.  In  this  opening,  the  orifice  of  the  urethra  was  situated. 

Dr.  Baillie*  has  mentioned  a case  which  appears  to  belong  in 
all  probability  to  the  present  division.  The  subject  of  it  was 
twenty-four  years  of  age.  She  had  always  passed  in  society  as 
a woman,  and  came  for  consultation  to  the  Nottingham  Hospital 
on  account  of  her  menses  never  having  appeared  ; a circum- 
stance, however,  that  had  in  no  way  affected  her  health.  The 
spurious  vagina  consisted  of  a cul-de-sac  two  inches  in  depth. 
Tlie  penis  was  of  the  size  of  the  female  clitoris,  but  there  were 
no  nymphse.  The  labia  were  more  pendulous  than  usual,  and  each 
of  them  contained  a body  resembling  a testicle  of  a moderate 
size,  with  its  cord.  The  look  of  the  individual  was  remarkably 
masculine,  with  plain  features,  but  no  beard.  The  mammae  resem- 
bled those  of  a woman.  The  person  had  no  desire  or  partiality 
for  either  sex. 

Adelaide  Preville,  who  had  been  married  as  a female,  died  in 
the  Hotel  Dieu  of  Paris.  In  examining  the  body  of  this  individual 
after  death,  Giraud^  found  that,  except  a perineal  cleft  or  false 
vagina  consisting  of  a cul-de-sac  placed  between  the  bladder  and 
rectum,  nothing  else  resembling  the  female  sexual  apparatus  could 
be  detected,  while  all  the  organs  belonging  to  the  male  sex  were 
present. 

Otto*  has  described  and  represented  (Fig.  3),  a case  of  the 
present  species  of  hermaphroditism,  in  an  individual  whose  history 
is  remarkable.  The  person  had  lived  ten  years  in  the  state  of  wed- 
lock with  three  different  men  ; but  at  the  age  of  thirty-five,  an 
action  of  divorce  Avas  brought  against  her  by  her  third  husband, 
accusing  her  of  being  affected  with  some  disease  of  the  sexual  parts 
that  rendered  the  connubial  act  on  his  part  extremely  difficult  and 
painful.  After  some  difference  of  opinion  between  the  two  medical 
men  to  whose  professional  examination  the  wife  Avas  submitted,  it 

^ Morbid  Anatomy,  2d  edition,  p.  410. 

^ Rccueil  Period,  dc  la  Soc.  dc  Med.  tom.  ii.  p.  315,  or  Moureaii’s  Hist.  Nat.  de 
la  Femme,  tom.  i.  p.  243  (with  a figure  of  the  parts). 

^ Neue  Seltene  Beobaehtungen  ziir  Anatomic,  etc.,  p.  123.  • 


428 


HEKMAPHllODITISM. 


was  at  last  considered  that  she  was  in  reality  a male  ; and  the  case 
finally  came  under  the  investigation  of  the  members  of  the  Royal 
Medical  College  of  Silesia,  who  confirmed  this  opinion.  The  imper- 
forated penis,  h,  was  one?  inch 
and  a half  in  length  ; the 
perineal  fissure,  e,  forming  the 
false  vagina,  was  at  the  pos- 
terior part  of  its  orifice,  bound- 
ed by  a distinct  frsenulum,  but 
Avas  of  a size  sufficient  to  re- 
ceive the  glans  of  the  husband 
for  an  inch  and  a half  in  depth. 
^ This  cavity,  as  well  as  the  in- 
ternal surfaces  of  the  two  lobes, 
a a,  of  the  divided  scrotum, 
-f  were  lined  with  a vascular  mu- 
cous membrane.  At  the  bot- 
t )m  of  it,  the  round  orifice  of 
^ t!ie  urethra,  d,  was  seen  to 
open  ; and  at  the  same  point 
a hard  mass  could  be  felt, 
probably  consisting  of  the  pro- 
Fig.  3.  state  gland  ; and  more  up- 

wards and  outwards,  nearly 
in  the  natural  situation  of  the  bulb,  was  seen  the  split  urethra,  c, 
with  a row  of  three  considerably-sized  openings,  / /,  which,  under 
pressure  and  irritation  of  the  genital  parts,  gave  out  several  drops  of 
a transparent  mucous  fluid.  Otto  considers  these  openings  as  the 
extremities  of  the  ducts  of  the  prostate  and  Cowper’s  glands,  and  of 
the  seminal  canals.  The  right  half  of  the  scrotum  contained  a small 
testicle  about  the  size  of  that  of  a boy  ten  years  of  age ; the  left 
testicle  lay  likewise  external  to  the  abdominal  ring,  and  was  still 
softer  and  smaller  than  the  right.  Both  were  furnished  with  sper- 
matic cords.  The  general  configuration  of  the  individual  was  strong, 
muscular,  and  meagre  ; the  beard  was  thin  and  soft,  and  the  face, 
mammae,  thorax,  pelvis,  and  extremities,  were  evidently  masculine. 

Along  with  the  preceding  instances  Ave  are  inclined  to  classify 
the  case  of  Maria  Nonzia,  as  detailed  by  Julien  and  Soules.'  This 
Fig.  3.  Hypospadiac  male. 

1 Ohserv.  sur  VHist.  Nat.  sur  la  Physique  ct  sur  la  Peinturc,  tom.  i.,  p.  18, 
witli  a plate. 


HYPOSPADIAS. 


429 


individual  was  born  in  Corsica  in  1695,  was  twice  married  as  a 
female,  and  at  last  divorced  in  1739  by  her  second  husband,  after 
having  lived  sixteen  years  in  wedlock.  Tlie  penis  was  two  inches  in 
length,  but  imperforate,  and  the  meatus  urinarius  was  placed  at  its 
root.  Two  bodies  like  ordinary-sized  testicles,  and  furnished  with 
spermatic  cords,  were  felt  in  the  divided  scrotum  ; and  there  was  a 
narrow  false  vagina  or  perineal  canal,  one  inch  and  three  lines  in 
depth,  and  crossed  at  its  upper  extremity  by  two  small  traversing 
membranous  bridles.  The  character  and  appearance  of  the  person 
were  masculine  ; the  visage  was  bearded  ; the  mamma)  were  as  fully 
developed  as  in  the  adult  woman ; but  the  nipples  were  each  sur- 
rounded with  hair. 

So  far  as  the  preceding  details  go,  they  seem  amply  sufficient  to 
justify  us  in  considering  Maria  Nonzia  as  a malformed  male ; and 
we  are  still  inclined  to  take  this  view  of  the  case,  notwithstanding 
the  statement  inserted  in  the  report  of  Julien  and  Soules,  that  the 
menses  were  present  as  in  other  women.  For,  not  to  insist  upon 
the  circumstance  that  the  reporters  do  not  show  that  they  made  any 
minute  or  satisfactory  inquiry  into  this  alleged  fact,  and  not  impro- 
bably took  it  upon  the  mere  word  of  the  subject  of  the  case,  who 
was  necessarily  greatly  interested  in  maintaining  the  reputed  female 
character,  it  would  be  requisite,  in  any  such  paradoxical  instance,  to 
ascertain  if  the  discharge  actually  agreed  in  character  with  the 
menstrual  fluid,  or  was  not  pure  blood,  the  result  of  a hemorrhage 
from  the  genito-urinary  passages,  or  from  the  rectum,  where,  as  in 
other  parts  of  the  body,  this  form  of  disease  frequently  assumes  a 
periodical  type.  We  would  be  inclined  to  apply  even  still  more 
strongly  these  remarks  to  the  celebrated  case  of  Hannah  Wild, 
detailed  by  Dr.  Sampson.^  This  person  had  evidently  the  male 
genital  organs  malformed  in  the  manner  mentioned  with  regard  to 
the  other  cases  included  under  the  present  section,  and  possessed  all 
the  secondar}"  sexual  peculiarities  of  the  male  ; so  that  we  can  only 
receive  with  great  doubt  and  distrust  the  alleged  existence  of  the 
menstrual  discharge,  and  the  more  so,  as  this  is  evidently  stated  on 
the  report  of  the  subject  of  the  case  alone,  who,  deriving  a precarious 
subsistence  from  the  exhibition  of  his  malformations,  had  a deep 
interest  in  amplifying  every  circumstance  that  could  enhance  the 
public  curiosity  with  respect  to  the  reality  of  his  hermaphroditic 
character. 

At  the  same  time,  however,  it  must  be  remarked,  that  in  some 
^ Epltem.  Nat.  Curios.  Dec.  i.  an.  iii.  p.  323. 


430 


HERMAPHRODITISM. 


instances  of  spurious  hermaphroditism,  it  is  found  extremely  difficult 
or  even  impossible  during  life  to  determine  with  precision  the  true 
or  predominant  sex  of  the  malformed  individual ; and  in  regard  to 
several  well-known  cases  oh  record,  we  find  on  this  point  the  most 
discrepant  opinions  offered  by  different  authors.  Thus,  while  Morand,' 
Arnaud,"  and  Delius,^  described  Michel- Anne  Drouart  as  a male ; 
Guyot,^  Ferrein,^  and  Caldani“  maintained  that  this  person  was  a 
female;  and  Mertrud'  regarded  the  individual  as  an  example  of  a 
real  hermaphrodite. 

A useful  lesson  of  caution  to  us  against  forming  too  decided  and 
dogmatic  an  opinion  in  cases  in  which  the  sexual  conformation  ap- 
pears in  any  marked  degree  doubtful,  has  lately  been  offered  in  the 
instance  of  ]\Iaria-Dorothee  Duriee,  or,  as  this  individual  was  named 
in  the  latter  years  of  his  life,  Charles  Durge.  While  Metzger®  con- 
sidered tliis  person  as  a specimen  of  that  kind  of  equivocal  sexual 
formation  to  which  the  designation  of  hermaphroditism  is  truly  ap- 
plicable, Hufeland,®  Mursinna,’®  Gall,  Brookes,"  and  others,’^  declared 
the  sex  of  Duriee  to  be  in  reality  female  ; and  Stark,‘®  Mertens,"  and 
tlie  Members  of  the  Faculty  of  Medicine  at  Paris,*®  were  equally  posi- 
tive in  regarding  the  individual  as  merely  a malformed  male.  The 
dissection  of  the  body  of  Duriee  by  Professor  Mayer  has,  as  we  shall 
afterwards  state  more  in  detail,  shown  the  sexual  conformation  of 
this  individual  to  consist  of  a mixture  of  both  the  male  and  female 
origans. 

O 

In  attempting  to  determine  the  true  sex  in  such  doubtful  in- 
stances of  sexual  formation  as  those  we  have  now  been  considering, 
we  are  inclined  to  attribute  very  little  v'eight  to  the  nature  of  the 
sexual  desires  of  the  malformed  individual,  as  we  have  already  found 
Adelaide  Preville,  the  dissection  of  vdiose  body  showed  him  to  he 
in  reality  a man,  living  for  some  years  before  death  in  the  capacity 
of  a wife,  and  the  same  remark  might  be  further  illustrated  by  a 
reference  to  Otto’s  and  other  cases. 

^ Mem.  de  V Acad,  dcs  Sc.  1750,  p.  165. 

^ Dissert,  sur  Ics  Hcrmajyhr.  p,  298.  • ^ Frank.  Sammhmg,  Th.  viii.  S.  398. 

Mem.  dc  V Acad,  des  Sc.  1756,  p,  71.  ® Ibid.,  1767,  p.  205. 

® Mem.  della  Societa  Italiana,  tom.  vii.  p.  130.  ^ Aniaud,  loc.  cit.  p.  298. 

^ Gcrxcht.-med.ic.  Ahhandlungcxi,  Hd.  i.  S.  177. 

Journ.  dcr  Praktischen  Hcilkunde,  l>d.  xii.  S.  170. 

Joxmi.  filr  die  Chinirgic  Arzneikunde,  etc.,  Bd.  i.  S.  555. 

Medical  Gazette  for  October  1836. 

Fon  clem  Neuangckommen  Ilcrmajyhx'od.  Berl.  1801. 

Neuen  Archiv  fiir  die  Gebiirtshiilfe,  Bd.  ii.  S.  538. 

Beschx-eibung  der  miinxilicken  Geschlechtstheilc  von  ]\r.  D.  Durrier  ; Leipzig, 
1802,  with  two  plates.  Med.  Gaz.  for  October  1836. 


HYPOSPADIAS. 


431 


A species  of  spurious  hermaphroditism,  similar  in  character  to 
that  which  we  have  just  described  in  man,  is  occasionally  met  with 
in  the  males  of  our  domestic  quadrupeds,  and  has  been  amply  illus- 
trated, as  it  occurs  in  these  animals,  by  Professor  Gurlt  in  his  work 
on  Veterinary  Medicine.  In  instances  of  this  malformation  among 
the  animals  to  which  we  refer,  the  hypospadiac  male  penis  has  usually 
been  found  of  a tortuous  ami  winding  form,  and  of  small  size.  In 
the  cases  in  which  the  fissure  of  the  parts  extends  through  the 
scrotum,  a false  vagina  is  seldom  formed,  as  in  man,  for  the  scrotum 
in  most  quadrupeds  lies  too  remote  from  the  perineum,  and  conse- 
quently from  the  normal  situation  of  the  vagina,  for  this  ])ui  pose ; 
but  in  some  examples  this  division  appears  to  be  carried  upwards 
into  the  perineum  itself,  leaving  a vaginal-like  opening,  in  which  the 
urethra  terminates.  The  testicles,  as  in  man,  are  sometimes  re 
tained  within  the  abdomen,  and  in  other  instances  descend  into  the 
scrotum.  They  are  frequently  small  in  size.  The  mamma  or  udder 
seems  to  be  often  well  developed. 

This  variety  of  hermaphroditic  malformation  has  been  met  with 
in  the  horse  by  Penchenati in  the  he-goat  by  Haller;'  and  in  the 
ram  by  the  same  author,*  and  by  Wagner,^  Wepfer,*  Stark,®  Gurlt,' 
Kauw  Boeihaave,®  and  A.  Cooper.®  We  have  seen  an  excellent 
specimen  of  this  malformation  in  the  last-mentioned  animal,  in  the 
museum  of  Dr.  Handyside  of  Edinburgh.  In  this  instance  the 
internal  male  organs  are  all  perfect ; the  large  testicles  are  situated 
in  the  halves  of  the  split  scrotum  ; the  penis  is  small  and  imperforate, 
and  a furrow  running  along  its  inferior  surface  is  continued  back- 
wards and  upwards  along  the  perineum  to  within  a short  distance 
from  the  anus,  where  it  leads  into  a canal,  into  which  the  urinary 
bladder  and  seminal  ducts  open.  This  canal  is  evidently  formed  of 
the  dilated  pelvic  portion  of  the  male  urethra ; its  orilice  is  com- 
paratively contracted,  but  corresponds  in  situation  with  the  vulva 
of  the  female.  We  have  seen  a second  similar  case  in  a ram,  in 
the  possession  of  Professor  Dick  of  the  Veterinary  School  of 
Edinburgh. 

There  is  another  variety  of  malformation  of  the  male  parts  occa- 

^ Mem.  de  V Acad,  de  Tiirin,  tom.  v,  p.  18. 

2 Conunent.  Soc.  Reg.  Sc.  Golting.  tom.  i.  p.  2,  tab.  i. 

* Ibid.,  p.  5,  tab.  ii.  Ephem.  Nnt.  Citrios.  Cent.  i.  ii.  p.  235. 

® Misccll.  Nat.  Curios.  Dec.  i.  ann.  iii.,  1672,  p.  255. 

® Ibid.,  Dec.  iii.  ann.  v.  vi.  p.  669.  ^ Lchrbiicli,  p.  193. 

® Nov.  Commevt.  Acad,  retropolit.  tom.  i.,  1750,  p.  315,  tab.  xi. 

9 Catalogue  of  Guy's  Hospital  Museum,  No.  2546. 


432 


HERMAPHRODITISM. 


sionally  found  in  quadrupeds,  which  is  allied  in  its  nature  to  the 
preceding.  In  this  second  species,  all  the  external  male  sexual 
organs  are  small ; the  short  penis  lies,  when  not  in  a state  of  erec- 
tion, upon  the  posterior  surface  of  the  enlarged  udder,  and  the  im- 
perfectly developed  testicles  are  generally  retained  within  the 
abdomen  ; or,  if  they  have  passed  out  of  that  cavity,  they  are  found 
situated  in  the  substance  of  the  udder.  The  vasa  deferentia,  pros- 
tate, and  Cowper’s  glands,  are  usually  of  their  normal  size  and 
appearance.  This  imperfect  hermaphroditic  formation  appears  to  be 
not  rare  among  horses,  several  instances  of  it  in  this  animal  having 
been  now  described  by  Arnaud,*  Gohier,"  Volmar,^  Pallas,^  Virey,* 
and  Gurlt.®  Anselmo^  and  Lecoq*  have  met  with  this  variety  of 
malformation  in  the  bull ; and  Sandford'*  has  described  an  instance 
in  the  calf,  which  seems  referable  to  the  same  head.  Gurlt'“  also 
notices  the  preparation  of  an  analogous  case  in  the  calf,  as  preserved 
in  the  museum  at  Berlin. 

TRUE  HERMAPHRODITISM. 

True  hermaphroditism  exists  as  the  normal  type  of  sexual  con- 
formation in  several  classes  of  the  vegetable  and  animal  kingdom. 
Almost  all  phanerogamic  plants,  with  the  exception  of  those  included 
under  the  class  Dioecia,  are  furnished  with  both  male  and  female 
reproductive  organs,  placed  either  upon  the  same  flower,  or,  as  in 
the  Linnsean  class  Monoecia,  upon  different  flowers  in  the  same  indi- 
vidual. In  the  class  Polygamia  various  exceptional  genera  are  in- 
cluded, which  present  indiscriminately  upon  the  same  individual,  or 
upon  different  individuals  of  the  same  species,  male,  female,  and 
hermaphrodite  flowers,  and  which  thus  form  a kind  of  connecting 
link  between  the  general  hermaphroditic  form  of  phanerogamic 
vegetables,  and  the  unisexual  type  of  the  monoecious  flowers  and 
the  dioecious  plants. 

From  anormalities  in  development,  these  normal  conditions  of 

^ Sur  les  Hcrmai^hrodites,  p.  282. 

2 Mem.  et  Observ.  sur  la  Chir.  et  la  Med.  Vet.  tom.  i.  p.  18. 

2 Archiv  fiir  Thierhcilkundc^  Ed.  iii.  S.  292. 

^ Bcschaft.  der  Gescllschaft  naturforcli.  Frcundc  zu  Berlin,  Ed.  iii.  S.  296. 

® Journal  Compl.  des  Sc.  Med.  tom.  xv.  p.  140. 

® Lehrhuch  der  Path.  Anat.,  Ed.  ii.  p.  189  ; and  taR.  viii.  fig.  6. 

^ Mem.  de  V Acad,  des  Sc.  dc  Turin,  tom.  ix.  p.  103,  figs.  1-3. 

® Journ.  Prat,  dc  Med.  Vet.  1827,  p.  102. 

® Med.  and  Phys.  Journal,  vol.  ii.  p.  305,  Avith  two  drawings. 

Loc.  cit.  p.  191. 


TllUE  LATERAL  HERMAPHRODITISM. 


. 433 


the  sexual  type  in  the  different  members  of  the  vegetable  kingdom 
are  occasionally  observed  to  be  changed.  Thus,  among  the  Dioccia, 
individual  plants  are  sometimes,  in  consequence  of  a true  malforma- 
tion, observed  to  assume  a hermaphroditic  type  of  structure ; or, 
on  the  other  hand,  in  hermaphroditic  plants  more  or  fewer  flowers 
are  occasionally  found  unisexual,  in  consequence  of  the  arrested 
development  of  one  order  of  their  sexual  organs  ; and  again,  though 
still  more  rarely,  from  an  excess  of  evolution,  a double  set  of  male 
parts,  or  a double  set  of  stamens,  is  seen  developed  on  some  of  the 
individual  flowers. 

In  the  animal  kingdom  we  find  instances  of  a perfect  herma- 
phroditic structure  as  the  normal  form  of  the  sexual  type  in  the 
Trematodes  and  Cestoides  among  the  Entozoa,  in  the  abranchial 
Annelida,  in  the  Planaria,  and  in  many  of  the  Mollusca,  particularly 
in  the  Pteropoda,  and  in  several  families  among  the  Gasteropoda. 
In  some  of  these  animals  that  are  thus  naturally  hermaphroditic,  the 
fecundation  of  the  female  organs  of  the  bisexual  individual  is  accom- 
plished by  its  own  male  organs ; but  in  others,  although  the 
anatomical  structure  is  strictly  hermaphroditic,  yet  the  union  of 
two,  or,  as  sometimes  happens,  of  more  individuals,  is  necessary  to 
complete  the  sexual  act ; and  during  it  the  female  organs  of  each 
are  respectively  impregnated  by  the  male  organs  of  the  other. 

In  the  Nematodes  and  Acanthocephali  among  the  Entozoa,  and 
in  the  Cephalopoda  and  Pectinibranchiate  Gasteropoda  among  the 
Mollusca,  as  well  as  in  all  symmetrically  formed  animals,  or,  in  other 
words,  in  those  whose  bodies  are  composed  of  a union  of  two  simi- 
lar halves,  as  in  the  Insecta,  Arachnida,  Crustacea,  and  the  Verte- 
brata,  the  male  and  female  organs  of  reproduction  are  placed  each 
upon  a different  individual  of  the  species,  constituting  the  basis  of 
distinction  between  the  two  sexes.  In  such  animals,  a mixture  of 
more  or  fewer  of  the  reproductive  organs  of  the  two  sexes  upon  the 
same  individual  appears  occasionally  as  a result  of  abnormal  forma- 
tion ; but  the  male  and  female  organs  that  co-exist  in  these  cases 
have  never  yet  been  found  so  anatomically  perfect  as  to  enable  the 
malformed  being  to  exercise  the  proper  physiological  function  of 
either  or  of  both  of  the  two  sexes.  This  form  of  true  hermaphro- 
ditism or  abnormal  mixture  upon  the  same  individual  of  the  organs 
of  the  two  sexes  in  the  higher  animals,  has  been  termed  “ unnatu- 
ral” or  “ monstrous,”  in  opposition  to  the  natural  hermaphroditism 
which  exists  as  the  normal  type  of  sexual  structure  in  some  of  the 
lower  orders  of  animals,  and  in  phanerogamic  plants.  The  malform- 


434  . 


HEKMAPIIRODITISM. 


ation  itself  is  observed  to  differ  greatly,  both  in  nature  and  degree, 
in  different  cases,  varying  from  the  presence  or  superaddition  of  a 
single  organ  only,  of  the  opposite  or  non-predominaut  sex,  up  to  the 
development  and  co-existence  of  almost  all  the  several  parts  of  the 
two  sexes  upon  the  same  individual.  In  describing  the  malforma- 
tion, we  shall  classify  its  various  and  diversified  forms  under  the 
three  general  orders  pointed  out  in  our  table  (p.  408),  including — 
1st,  lateral ; 2dly,  transverse;  and  3dly,  double  or  vertical  hermaj^h- 
roditisni. 

A.  TRUE  LATERAL  HERMAPHRODITISM. 

According  to  the  opinion  of  many  physiologists  of  the  present 
day,  the  two  lateral  symmetrical  halves  of  the  body,  and  even  the 
two  halves  of  all  its  single  mesial  organs,  are  originally  developed 
in  a great  degree  independently  of  one  another.  Granting  this 
point  in  the  doctrine  of  eccentric  development,  we  can  easily  con- 
ceive how,  in  the  same  embryo,  an  ovary  might  be  formed  on  one 
Wolffian  bod}^,  and  a testicle  on  the  other ; or,  in  other  words,  how 
female  organs  might  be  developed  on  one  side,  and  male  organs  on 
the  other.  It  is  the  existence  of  such  an  unsymmetrical  type  of 
sexual  structure  upon  the  two  opposite  sides  of  the  body  of  the 
same  individual,  that  constitutes  the  distinctive  characteristic  of 
lateral  hermaphroditism. 

Instances  of  this  species  of  true  hermaphroditic  malformation 
have  been  observed  in  many  different  classes  of  animals,  as  well  as 
in  the  human  subject. 

Individual  examples  are  sometimes  observed  among  insects, 
particularly  among  tlie  Lepidoptera,  in  which  all  the  different  parts 
of  the  two  sides  or  lateral  halves  of  the  body  are  formed  after  op- 
posite sexual  types.  We  shall  afterwards  have  occasion  to  notice 
different  examples  of  this  form  of  lateral  hermaphroditism  as  seen 
in  the  general  conformation  of  the  body,  but  may  here  state  that  in 
two  or  three  instances  such  malformed  insects  have  been  carefully 
dissected,  and  found  to  present,  in  the  anatomical  structure  of  their 
sexual  organs,  a mixture  of  the  organs  of  the  male  and  female. 

In  a Melitoea  dldymus  described  by  Klug,^  the  general  external 
characters  were  those  of  the  male,  but  the  left  eye,  palpus,  and 
antenna,  and  the  left  sexual  ffing,  were  smaller  than  in  individuals 
beloimim*:  to  this  sex  : and  the  left  antenna  was  annulated  with 
white  and  yellow  at  the  apex,  while  the  right  was  of  one  colour. 

^ Froriep's  Notizen,  vol.  x.  p.  183. 


TRUE  LATERAL  HERMAPHRODITISM. 


435 


On  dissection,  the  various  male  sexual  parts  were  present,  and  they 
had  appended  to  them  a free  female  ovary  situated  upon  the  left, 
and  united  to  no  other  organ. 

In  a Gastropliaga  quercifolia  dissected  by  Schultz,  and  desci'ibed 
by  Eu(lolphi,‘  the  left  side  appeared  externally  male,  and  the  right 
female,  with  a distinct  line  of  separation  throughout  the  vdiole 
body.  On  dissection,  Schultz  discovered  an  ovarium  upon  the  right 
side,  and  two  testes  upon  the  left.  The  oviduct  of  the  ovary  joined 
the  canal  of  the  vasa  deferentia  about  two  inches  before  its  termina- 
tion ; and  the  spermatheca  was  connected  with  the  common  eva- 
cuating duct.  The  two  testicles  on  the  left  side  were  placed  one 
behind  the  other,  and  connected  by  a thin  vessel.  The  spermatic 
duct  belonging  to  one  of  the  testicles  immediately  received,  as  in 
the  Lepidoptera,  the  spiral  vessel ; farther  beyond,  and  on  the  op- 
posite side,  a second  vessel,  which  appeared  to  consist  of  the  rudi- 
mental  spermatic  duct  of  the  other  testicle,  opened  into  it.  The 
oviduct  of  the  ovary  joined  the  canal  of  the  vasa  deferentia  about 
two  inches  before  its  termination  in  the  penis,  and  a female  sperma- 
theca was  connected  with  the  common  distended  evacuating  duct.2 

A well-marked  example  of  lateral  hermaphroditism  among  the 
Crustacea  has  been  recorded  by  Dr.  Nicholls.'^  In  a lobster 
inarinus),  he  found  on  the  right  side  of  the  body  a female  sexual 
aperture  in  its  normal  situation  at  the  root  of  the  third  leg,  and  con- 
nected with  a regularly  formed  oviduct,  fall  of  ova.  On  the  left 
side  of  the  animal  there  was  a male  sexual  aperture  placed,  as 
usual,  at  the  root  of  the  fifth  leg,  and  connected  internally  with  an 
equally  perfect  testicle  and  spermatic  cord.  The  general  external 
conformation  of  the  animal  corresponded  Avith  its  internal  sexual 
structure,  the  right  lateral  half  of  the  body  presenting  all  the  second- 
ary characters  and  peculiarities  of  the  female,  and  the  left  all  those 
of  the  male ; so  that  if  split  from  head  to  tail,  to  use  Dr.  Nicholls’ 
mode  of  expression,  the  animal  Avould  haA^e  been  perfectly  female  on 
the  right  side,  and  perfectly  male  on  the  left. 

The  investigations  of  Sir  E.  Home^  led  physiologists  some  years 
ago  to  believe  that  among  Fishes  lateral  hermaphroditism  constituted 
the  natural  type  of  sexual  formation  in  the  genera  Myxine  and 

^ Ahhandlung.  clcr  Kdnig.  Akad.  zu  Berlin,  1825,  s.  55. 

" See  also  drawings  of  the  body  and  genital  organs  of  a hermaphrodite  Sphinx 
populi  in  Fischer’s  Oryctographie  du  Gouvernement  de  Moscou  : Moscow,  1830. 

" Phil.  Trans,  for  1730,  No.  413,  vol.  xxxvi.  p.  290,  with  drawings  of  the 
animal  and  of  its  reproductive  organs.  ^ Phil.  Imrans,  for  1823.  Art.  xii. 


43G 


IIERMAPHKODITISM. 


Petromyzon ; but  the  later  and  more  accurate  observations  of 
Rathke^  have  shown  that  these  species  are  strictly  bisexual,  and 
that  the  opposite  opinion  had  arisen  from  the  kidneys  of  the  female 
having  been  mistaken  for  the  male  testicles.  Various  instances, 
however,  are  on  record  of  fishes,  known  to  be  normally  bisexual, 
presenting  from  abnormal  development  a lateral  hermaphroditic 
structure,  or  a roe  on  one  side  and  a milt  on  the  other.  Such  a 
hermaphroditic  malformation  has  been  met  with  in  the  genera 
Salmo^  Gadus^  and  Cupriims*  and  in  the  Merlangus  vulgaris^  Aci- 
'penser  huso,^  and  Esox  luciusJ 

Of  lateral  hermaphroditism  in  Birds,  we  have  one  instance  re- 
corded by  Bechstein,^  in  a chicken  that  had  a testicle  on  the  right 
side  of  the  body,  and  an  imperfect  reniform  ovary  on  the  left.  The 
external  appearance  of  the  bird  presented  a mixture  of  the  cha- 
racters of  tlie  two  sexes. 

Rudolphi  has  referred  to  a second  and  more  ancient  example  of 
lateral  hermaphroditism  in  the  hen,  mentioned  by  Heide.®  The  case, 
entitled  by  the  author  “ galli  qui  putabatur  hermaphroditus  anatome 
rudis,”  is  so  imperfectly  detailed  as  not  to  be  entitled  to  much 
attention. 

I have  been  fortunate  enough  to  meet  with  two  domestic  fowls 
that  presented  in  their  sexual  form  and  organisation  examples  of 
lateral  hermaphroditism.  In  the  first  of  these  cases  (Fig.  4),  the 
female  sexual  organs  were  placed  on  the  left  side  of  the  body,  and 
the  ovary,  a,  and  oviduct,  h,  were  in  all  respects  apparently  naturally 

^ Bc'inerkungen  ilbcr  den  Innern  Ban  der  PricTce,  s.  119.  See  also  additional 
observations  by  the  same  author  in  Muller’s  Arcliiv  fur  Anatomie,  etc.,  for  1836. 
Heft  ii.  s.  171.  The  older  error  of  Cavolini,  who  supposed  that  he  had  detected 
two  ovaries  and  two  testicles  in  the  Perea  marina  and  Labrus  clmnna  {Sulla  Gene- 
razione  del  Pesclii  et  die  Granchi,  Nap.  1787),  had  been  previously  shown  by 
Hudolphi  to  depend  upon  his  having  mistaken  undeveloped  portions  of  the  ovaries 
for  testicles.  Schweigger’s  SkelelloseJThiere,  s.  204  ; and  Ahhandlungcn  Konig. 
Akad.  der  Wissenseliaft  zii  Berlin,  1825,  p.  48. 

^ Commercium  Litter.  Norini.  1734,  Hebd.  39. 

^ Pipping,  Vetensk.  Akad.  nya  Handl.  1800,  Bd.  xxi.  s.  33,  tab.  i.  fig.  1 ; 
Leuwenhoeck,  Experim.  et  Contempl.  p.  150  ; Eph.  Nat.  Cur.  Dec.  i.  ann.  i.  obs. 
125  ; Du  Hamel,  Traite  des  Poissons,  Part  ii.  p.  130. 

^ Alischer,  Breslau  Sammlung.  1720,  p.  645  ; Morand,  Mem.  de  V Acad,  des 
Sc.  1737,  p.  72  ; Schwalbe,  Comvicr.  lAt.  Norimb.  1734,  p.  305. 

^ Marchant,  Mem.  de  V Acad,  des  Sc.  1737,  p.  12  ; Baster,  Opusc.  Subscesiva, 
tom.  i.  p.  138.  Pallas,  Bcise  durch  Paisse,  etc.,  Theil.  ii.  s.  341. 

^ Peaumur,  Mhn.  de  V Acad.  1737,  p.  51  ; Starke,  Epili.  Nat.  Cur.  Dec.  iii. 
ann.  vii.  and  viii.  obs.  109. 

8 Naturgcschichte  der  Vogel,  etc.,  1807,  Bd.  ii.  s.  1219. 

® Anatome  Myfuili:  subjecta  est  Centuria  Obscr.  Amsterdam,  1684,  p.  193,  obs.  95. 


LATERAL  HERMAPHRODITISM  IN  BIRDS. 


437 


formed.  On  the  right  side,  a male  vas  deferens,  (/,  of  about  half 
the  normal  length,  ran  up  the  cloaca  to  opposite  the  origin  of  the 
iliac  vessels,  c,  and  during  this  part 
of  its  course  was  bent  into  those 
short  transverse  zigzag  folds  which 
characterise  the  structure  of  this  part 
in  the  common  cock.‘  When  it 
reached  the  middle  third  of  the 
kidney,  d d,  it  lost  this  particular 
form,  became  membranous,  e,  and 
after  proceeding  upwards  for  about 
an  inch,  in  the  common  course  of 
the  canal,  at  last  disappeared.  The 
convuluted  or  contorted  portion  ran 
over  a space  of  about  two  and  a 
half  inches,  and  if  unrolled  would 
have  extended  three  or  four  times 
that  length.  Its  canal  was  about 
the  usual  size  of  the  same  part  in 
the  perfect  cock,  and  perhaps  at 
some  parts  even  more  dilated.  Its 
cavity  was  filled  with  a whitish 
seminal-looking  albuminous  fluid, 
which  at  first  prevented  a mercurial 
injection  from  readily  passing  through 
it.  There  was  not  any  apparent  ves- 
tige of  a testicle.  The  fowl  that 
was  the  subject  of  this  malformation 
possessed  in  an  imperfect  degree 
the  plumage,  comb,  spurs,  and 
general  appearance  of  the  cock,  and 
when  young  was  considered  to  be  a male  until  the  time  it  com- 
menced to  lay  eggs,  which  it  did  very  constantly,  except  during  the 
moulting  season,  up  to  the  time  of  its  death.  ^Its  eggs  were  re- 
marked to  be  very  large.  They  had  repeatedly  been  tried  to  be 
hatched,  but  always  without  success.  The  bird  itself  was  never 
known  to  incubate.  It  was  peculiar  in  its  habits  in  so  far  that  in 
the  barn-yard  it  did  not  associate  with  the  other  poultiy,  and  at 


d - 


Fig.  4. 


Fig.  4.  Lateral  Hermaphroditism  in  domestic  fowl. 


* See  Cyd.  of  Anat.  and  Phys.,  vol.  i.  p.  354.  Article  “ Aves.” 


438 


HERMAPHRODITISM. 


night  roosted  separately  from  them.  It  crowed  regularly,  especially 
in  the  morning,  and  often  attempted  copulation  with  the  hens. 

In  the  second  case,  the  ovaries  and  oviduct  on  the  left  side  of 
the  body  were,  as  in  the  former  example,  natural  in  themselves ; 
but  in  the  mesometry  of  the  oviduct  a tube  of  the  size  of  the  male 
vas  deferens  was  found.  This  tube,  like  the  normal  vas  deferens, 
was  thrown  into  the  distinctive  angular  folds.  It  ran  for  about  an 
inch  and  a half  through  the  upper  portion  of  the  mesometr};",  was 
blind  at  either  extremity,  and  admitted  of  being  injected  Avith 
quicksilver.  On  the  right  side  there  was  also  a male  vas  deferens, 
marked  Avith  the  characteristic  angular  folds.  The  contorted  por- 
tion of  this  canal  only  stretched — in  this  instance — to  about  an 
inch  above  the  cloaca ; but  the  folds  Avere  even  stronger  than  in  the 
first  case,  and  the  tube  itself  Avas  rather  more  dilated.  Above  or 
anterior  to  this  convoluted  part,  the  tube  became  straight  and  mem- 
branous, and  ran  up  in  this  form  for  about  tAvo  inches  in  its  usual 
track  over  the  abdominal  surface  of  the  kidney ; but  there  Avas  not 
at  its  upper  extremity  any  trace  of  a testicle.  This  bird  presented 
during  life,  in  a very  slight  degree  only,  the  appearance  of  a cock, 
its  comb  and  spurs  being  even  less  developed  than  in  the  previous 
case.  It  shoAved  the  same  solitary  habits  in  the  poultry-yard.  It 
laid  eggs  regularly.  On  three  different  occasions  I had  a number 
of  them  submitted  to  incubation,  but  in  none  of  them  Awas  a chick 
produced. 

In  the  Quadruped,  Schlump'  has  mentioned  an  instance  of  lateral 
hermaphroditic  malformation.  In  a young  calf  he  found  on  the  left 
side,  under  the  kidney,  a small  testicle  having  attached  to  it  a vas 
deferens,  Avhich  Avas  connected  Avith  the  peritoneum  toAvards  the 
abdominal  ring  of  the  same  side,  and  there  became  lost  in  the  cell- 
ular texture  of  the  part.  An  ovary  and  Fallopian  tube,  Avith  a 
uterus  consisting  of  a single  horn  only,  Avere  connected  to  the  right 
side  of  the  loins  by  a ligament.  The  neck  of  the  uterus  lost  itself 
in  the  cellular  substance  beneath  the  rectum,  and  there  AA^as  no 
Aaigina.  The  external  organs  Avere  male,  but  imperfectly  formed. 
The  udder  occupied  the  place  of  the  scrotum.^ 

1 Arcliiv  fur  die  Thierheillmnde,  Bd.  ii.  Hft.  ii.  s.  204. 

2 In  the  Gazette  Medicate  de  Paris  for  1844,  p.  530,  Bertrand  describes  a lier- 
mapliroditic  sheep,  liaving  a testis  and  epididymis  in  the  left  side  of  tlie  scrotum, 
and  with  a vas  deferens  leading  from  it  to  a fully-develqped  ovary  on  the  riglit. 
There  Avas  a uterus,  and  blind  Fallopian  tubes,  and  an  imperforate  v'agina  ; and 
on  the  right  or  female  side,  a rudiment  also,  apparently  of  a vas  deferens. 


LATERAL  HERMAPHRODITISM  IN  MAN. 


430 


In  the  human  subject,  several  different  instances  of  sexual  mal- 
formation have  now  been  met  with,  referable  to  the  head  of  lateral 
hermaphroditism.  In  these  cases,  along  with  a testicle  on  one  side, 
and  an  ovary  on  the  other,  tliere  has  generally  co-existed  a more  or 
less  perfectly  formed  uterus.  The  external  parts  have  differed  in 
their  sexual  characters,  in  some  instances  being  female,  in  others 
male,  and  in  others  again  of  a neutral  or  indeterminate  type. 

In  man,  and  in  the  higher  quadrupeds,  Ave  have  not  unfrequently 
exhibited  to  us  a slight  tendency  to  this  unsymmetrical  type  of 
sexual  structure,  constituting  true  lateral  hermaphroditism,  in  the 
testicle  of  one  side  only  descending,  Avhilst  the  other,  in  consequence 
of  imperfect  development,  remains  within  the  inguinal  ring.  In  the 
single  unsymmetrical  ovary  of  most  female  birds  and  some  fishes,^ 
Ave  see  a still  nearer  approach  to  the  state ; and  it  is  Avorthy  of 
remark  that,  am.ong  birds  at  least,  the  single  ovary  is  ahvays  placed 
upon  the  left  side.  In  lateral  hermaphrodites  in  the  human  subject, 
the  left  side  also  appears  to  be  that  on  Avhich  Ave  most  frequently 
meet  with  the  female  type  of  the  sexual  organs.  We  shall  divide 
the  following  cases  according  to  the  particular  sides  Avhich  Avere  re- 
spectively male  and  female  in  them. 

1.  OVARY  ON  LEFT  SIDE,  AND  TESTICLE  ON  THE  RIGHT. 

a.  M.  Sue  met,  in  1746,  Avith  an  instance  of  this  subdivision  of 
lateral  hermaphroditism  in  the  human  subject,  in  a young  person, 
thirteen  or  fourteen  years  of  age,  Avhose  case  A\"as  the  subject  of  a 
thesis  sustained  by  M.  Morand.^  Of  the  internal  genital  organs, 

^ In  the  early  embryo  of  birds,  the  ovaries  are  originally  double,  as  pointed 
out  by  Einmert  (see  Reil’s  ytrc/a'w  for  1811);  and  as  was  previously  known  to 
AVolff  and  Hochstetter  {Anat.  Tliil.  tom,  i.  p,  349). 

2 Da  Hcrmaphroditis,  Paris,  1749.  This,  according  to  Arnaud  (p.  323),  is  the 
same  case  of  lateral  hermaphroditism  with  that  described  by  Lecat.  If  so,  the 
latter  author  (probably  from  drawing  his  description  from  memory,  and  not,  as 
Morand  seems  to  have  done,  from  the  parts  placed  before  him),  has  stated  that, 
along  with  the  testicle  and  vas  deferens  on  the  one  side,  there  existed  a vesicula 
seminalis,  and  that  both  sides  Avere  provided  Avith  round  ligaments,  the  one  on 
the  male  side  forming  probably  one  of  the  two  tubes  described  by  Morand  as 
arising  from  the  testicle.  Meckel  (Keil’s  Archiv,  Bd.  xi.  s.  322)  considers 
lyiorand’s  and  Lecat’s  as  tAvo  different  cases,  and  points  out  that  Avhat  is  described 
as  the  male  side  in  the  one,  Avas  the  female  in  the  other,  and  vice  versa.  It  is 
perhaps  not  uiiAvorthy  of  remark  that,  in  the  coloured  plate  accompanying  the 
translation  of  Morand’s  case  by  Gautier,  the  male  and  female  sides  have  been 
reversed  from  an  error  in  the  engraving  ; and  this  circumstance  may  haA'e  con- 
tributed to  mislead  Lecat  in  his  description,  provided  he  happened  to  look  at  this 
notice  of  the  case. 

84: 


440 


HERMAPHRODITISM. 


there  existed  on  the  left  side  a very  distinct  ovary,  a round  ligament 
which  ran  outwards  to  the  groin  of  the  same  side,  and  a well-formed 
Fallopian  tube  with  its  usual  fimbriated  extremity.  The  other  ex- 
tremity of  the  Fallopian  tube  terminated  in  the  fundus  of  the  uterus, 
which  occupied  its  usual  situation  between  the  bladder  and  rectum. 
On  the  right  side,  again,  there  was  a slender  elongated  testicle,  which 
had  moved  forwards  to  the  corresponding  inguinal  canal,  but  had 
not  proceeded  so  far  as  to  pass  out  of  the  abdominal  cavity.  On 
the  superior  part  of  the  testicle  was  a body  resembling  the  epididy- 
mis, and  the  testicle  itself  sent  off  two  tubes,  which  afterwards 
united  into  one  immediately  before  their  insertion  into  the  uterus. 
The  external  genital  organs  were  those  of  a hypospadiac  male,  and 
during  life  the  person  had  been  always  looked  upon  as  belonging  to 
the  male  sex.  The  perineal  canal  or  vagina  terminated  between  the 
scrotum  and  root  of  the  imperforate  penis,  in  a very  small  opening, 
which  was  common  to  it  and  to  the  meatus  urinarius. 

h.  In  1754,'  a young  person  of  about  eighteen  years  of  age  died 
in  the  Hotel  Dieu  of  Paris ; and  in  dissecting  his  body,  the  anatomist 
Yarole  found  the  reproductive  organs  malformed  in  the  following 
manner : — On  the  right  side  the  scrotum  contained  a testicle,  and 
the  vas  deferens  arising  from  it  opened,  not  as  usual  into  the  neck, 
but  into  the  middle  of  the  external  border  of  the  corresponding 
vesicula  seminalis.  On  the  left  side  the  scrotum  was  empty ; and 
internally  on  this  side  there  were  found  an  ovary,  a Fallopian  tube 
with  its  fimbriated  extremity,  a small  oval  uterus  without  a neck  and 
somewhat  flattened,  and  a broad  and  a round  ligament,  the  last  of 
which  ran  outwards,  and  was  lost  in  the  cellular  tissue  of  the  left 
half  of  the  scrotum.  The  vesicula  seminalis  on  the  right,  and  the 
imperfect  uterus  on  the  left  side,  communicated  by  a canal  of  an 
inch  and  a half  in  length.  The  external  organs  were  male  ; but 
the  penis  was  very  small,  had  no  corpus  spongiosum,  and  Avas  im- 
perforate for  half-an-inch  at  its  anterior  extremity.  The  mammre 
Avere  as  large  as  in  Avomen  of  the  same  age.  The  individual  had 
been  regarded  during  life  as  a male. 

c.  In  1825,  the  late  Professor  Eudolphi"  detailed  to  the  Academy 
of  Sciences  at  Berlin  the  case  of  an  infant  Avho  Avas  reported  to  have 
died  seven  days  after  birth,  and  Avhose  sexual  organs  exhibited  the 
folloAving  interesting  instance  of  lateral  hermaphroditic  conforma- 
tion. On  the  left  side  Avere  discovered  an  ovary  (Fig.  G,  a),  AAnthout 

^ Mem.  cle  la  Soc.  Med.  de  Paris,  tom.  iv.  p.  342. 

2 Ahhandlung.  Konig.  Akad.  dcr  Wissenschaft  zu  Berlin,  1825,  s.  60. 


CASES  OF  KUDOLPIII,  MAYER,  ETC. 


441 


a distinct  broad  ligament,  and  a Fallopian  tube,  h,  which  communi- 
cated with  the  superior  and  left  portion  of  a uterus,  c.  The  left 
side  of  the  scrotum  (Fig.  5,  a)  was  empty  ; the  right,  &,  contained  a 
testicle  (Fig.  6,  d)  furnished  with  an  epididymis,  e,  and  tortuous  vas 
deferens,  /.  Below  the  uterus  there  was  a hard  flattened  ovoid 
body  (Fig.  6,  y,  and  Fig.  7,  h),  which,  when  divided,  was  found  to 
consist  of  a cavity  with  thick  parietes,  and  was  considered  by 


Budolphi  as  the  prostate  gland  in  a rudimentary  state.  The  mouth 
of  the  uterus  (Fig.  7,  a)  terminated  below  in  the  parietes  of  this  ovoid 
body,  and  on  the  right  the  vas  deferens,  d,  penetrated  into  its  sub- 
stance, but  without  opening  into  its  cavity.  At  the  inferior  part  of 
the  uterus  there  was  a true  vagina,  c,  which  terminated  in  a cul-de- 
sac.  The  anus,  rectum,  and  other  organs,  were  natural.  The 
external  sexual  parts  were  male,  but  the  penis  was  divided  in- 
feriorly  (Fig.  5,  c).  The  testicle  and  ovary  were  supplied  with  the 
usual  spermatic  arteries  (Fig.  6,  li  h). 

d.  In  1851,  a well-marked  case  of  lateral  hermaphroditism  was 
found  in  Dublin,  and  I have  seen  and  examined  the  malformed 
parts  in  the  College  of  Surgeons’  Museum  in  that  city.  The  sub- 
ject of  it,  a supposed  male  convict,  aged  26,  Avas  dissected  by  Dr. 
Banon,  who  has  published  an  accurate  and  excellent  account  of  the 
case,  Avith  illustrative  drawings.^  Externally  the  penis  Avas  of  the 
usual  size  and  structure  of  that  organ  in  the  male  adult ; but  it  Avas 
imperforate — the  urethra  opening  inferiorly  at  its  root,  betAveen  the 
bifurcations  of  a substance  resembling  the  corpus  spongiosum.  The 


Fig.  5.  External  organs. 

Fig.  6.  Uterus,  turned  downwards  and  forwards  to  sliow  its  posterior  surface 
and  connections,  etc. 

Fig.  7.  Os  uteri,  vagina,  prostate,  and  vas  deferens.  - 


^ Dublin  Journal  of  Medical  Science  for  1852,  p.  66. 


442 


HERMAPHRODITISM. 


divided  scrotum  or  labia  gave  lower  down  the  appearance  of  the 
female  vulva,  with  nymphee  and  a small  vaginal  orifice  contracted  by 
a crescentic  hymen.  Internally,  this  vaginal  orifice  and  a very 
narrow  vaginal  canal  led  upwards  to  a small  well-formed  uterus, 
which  bore  the  exact  relations  to  the  bladder,  rectum,  and  peri- 
toneum, that  this  organ  has  in  the  normal  female,  and  was  provided 
latterally,  like  it,  with  broad  ligaments.  The  uterus  opened  into  the 
vaginal  cavity  below,  and  from  its  left  corner  superiorly  there  was 
given  off  a very  tortuous  and  twisted,  but  perfectly  permeable  Fallo- 
pian tube,  which  terminated,  as  usual,  at  its  farther  extremity,  in  a 
corpus  fimbriatum.  On  lifting  up  this  fimbriated  extremity,  it  was 
found  to  rest  on  an  ovary  bound  to  the  peritoneum,  and  thrown 
somewhat  across  to  the  right  side  in  the  recto-vaginal  space.  There 
Avas  no  trace  whatever  of  a right  Fallopian  tube  or  right  ovary ; but 
in  their  stead  there  was  a male  testicle,  lying  also  in  the  recto-vaginal 
space,  and  provided  with  a long  epididymis  which  ended  in  a per- 
meable vas  deferens  that  took  an  unusual  course,  for  it  first  passed 
forwards  and  outwards  in  its  normal  course,  nearly  in  the  direction 
of  the  internal  abdominal  ring,  and  then  suddenly  turned  backwards 
and  downwards  towards  the  uterus,  ran  along  between  the  layers  of 
its  right  broad  ligament,  became  more  and  more  slender,  and  per- 
forated at  last  obliquely  through  the  right  side  of  the  organ  into  the 
uterine  cavity.  There  was  no  appearance  of  a A^esicula  seminalis  or 
prostate  gland,  and  no  trace  of  a second  testis  or  vas  deferens.  The 
testicle  which  was  present  seemed  as  perfect  as  in  the  normal  male  ; 
it  was  provided  Avith  a tunica  albuginea,  and  beneath  this  Avas  found 
the  delicate  tunica  vascula,  and  internally  the  tubular  structure 
peculiar  to  this  organ.  A small  quantity  of  fluid  taken  from  the 
commencement  of  the  vas  deferens  had  the  peculiar  odour  and  con- 
sistence of  the  human  semen,  but  on  microscopic  examination  no 
spermatozoa,  only  numerous  cells  containing  granules,  Avere  seen  in 
it.  The  shape  and  connections  of  the  ovary  Avith  the  fimbriated 
extremity  of  the  Fallopian  tube  Avere  such  as  are  seen  in  the  normal 
female ; and  on  division  it  presented  the  usual  stromal  tissue ; but 
no  appearance  of  Graafian  vesicles  could  be  detected  in  it.  The 
subject  of  the  preceding  malformation  Avas  baptized  as  a girl,  but 
afterAvards,  in  consequence  of  the  increasing  size  of  the  organ  repre- 
senting the  penis,  he  Avas  brought  up  as  a male,  and  died  of  phthisis, 
Avhen  under  sentence  of  transportation  for  sheep-stealing.  His  voice 
was  masculine  ; he  excelled  in  several  of  the  manly  exercises ; liis 
sexual  desires  appear  to  have  been  slight,  but  those  of  a male ; and 


CASES  OF  EUDOLPHI,  MAYER,  ETC. 


443 


his  general  configuration  and  appearance  were  those  of  a man,  with 
* the  exception  that  there  were  but  slight  traces  of  beard.  The  pelvis 
was  fan-like,  and  somewhat  feminine  in  form. 

e.  Under  the  present  section  of  lateral  hermaphroditism,  we  may 
also,  according  to  Mayer’s  report,  include  the  celebrated  case  of 
Maria  Duriee,  or  Charles  Durge.’  This  person  was  baptized  and 
brought  up  as  a female,  but  at  forty  years  of  age  was  persuaded  to 
change  his  name  and  dress  to  those  of  a man.  We  have  already 
(p.  430)  alluded  to  the  great  diversity  of  opinion  which  was  enter- 
tained by  the  medical  men  of  Europe  in  regard  to  the  true  sex  of 
this  individual.  Even  the  different  parts  of  his  body  were  at  one 
time  referred  to  the  male  type,  and  at  another  time,  and  by  other 
persons,  to  the  female.  The  pelvis  was  the  only  part  that  was 
generally  considered  as  decidedly  female,  yet  the  inspection  of  the 
body  after  death  by  Professor  ]\Iayer  showed  that  even  in  this 
respect  all  were  in  error. 

Of  the  female  sexual  organs  there  existed  a uterus,  vagina,  two 
Fallopian  tubes,  and  an  ovary ; and  of  tlie  male,  a testicle,  prostate 
gland,  and  penis.  The  uterus  was  placed  in  its  normal  situation 
between  the  urinary  bladder  and  rectum,  but  with  its  fundus  directed 
in  some  degree  to  the  left.  The  organ  was  extremely  narrow,  and 
two  and  a half  inches  in  length.  The  cavity  of  its  cervix  presented 
on  its  inner  surface  some  slight  folds,  but  would  scarcely  admit  a 
quill ; the  cavity  of  its  fundus  was  nearly  half-an-inch  across.  The 
small  canals  of  two  Fallopian  tubes  opened  into  the  fundus  uteri. 
Their  abdominal  extremities  were  shut,  but  the  corpora  fimbriata 
were  present.  Near  the  extremity  of  the  right  Fallopian  tube, 
which  was  four  inches  and  four  lines  in  length,  a small  flattened 
almond-shaped  body  was  placed,  which,  on  examination,  proved  to 
be  distinctly  a testicle.  It  was  completely  enveloped  in  peritoneum, 
and  received  a cord  composed  of  muscular  fibres,  and  of  a spermatic 
vein  and  artery.  Its  internal  structure  was  yellow  and  filamentous, 
like  that  of  the  testicle,  and  its  seminiferous  tubes  could  be  easily 
separated.  The  left  Fallopian  tube  was  an  inch  shorter  than  the 
right ; and  a little  outside  and  behind  its  abdominal  extremity 
another  small  flattened  body  was  found  inclosed  in  the  peritoneum. 
It  resembled  an  ovary  rather  than  a testicle.  Its  tissue  was  com- 
posed of  small  granules  conglomerated  together.  The  penis  was 
two  inches  and  nine  lines  in  length,  and  was  for  the  greater  part 

^ Gazette  Med.  de  Paris,  1836,  No.  39  ; Lancet,  vol.  i.  for  1836-37,  p.  140  ; or 
London  Medical  Gazette  for  October  29,  1836. 


444 


HEaMAPHRODITISM. 


concealed  beneath  the  inons  veneris.  During  life  it  was  capable  of 
erection,  and  was  then  elongated  to  more  than  three  inches.  The 
prepuce  covered  only  half  of  the  glans.  There  was  not  any  corj^us 
spongiosum.  A fossa  or  groove,  representing  a urethral  canal 
divided  interiorly,  ran  along  the  under  surface  of  the  penis.  The 
two  folds  of  skin  forming  the  sides  of  the  groove  separated  from 
each  other  posteriorly,  and  might  be  compared  to  nymph ae.  To- 
wards the  root  of  the  penis,  by  uniting  interiorly  with  a puckering 
of  the  skin  of  the  labia  majora  or  divided  halves  of  the  scrotum, 
they  formed  a circular  orifice  not  larger  than  a quill,  having  some 
bodies,  supposed  to  be  vestiges  of  the  carunculae  myrtiformes,  at  its 
lower  edge,  and  leading  to  a short  vestibule,  or  common  canal,  into 
which  the  urethra,  surrounded  by  a firm  but  small  prostate,  entered 
from  above,  and  the  vagina,  encircled  at  its  entrance  by  a vascular 
ring  of  varicose  veins,  opened  from  below.  The  vagina  was  two 
inches  and  eight  lines  in  length,  and  only  ten  lines  at  its  greatest 
breadth.  Its  inner  surface  was  somewhat  wrinkled  anteriorly,  but 
smooth  behind.  It  terminated  above  in  a kind  of  spongy  isthmus 
representing  the  blind  orifice  of  the  uterus,  and  from  four  to  six 
lines  in  length.  The  diameters  and  form  of  the  pelvis  were,  on  dis- 
section, found  to  be  most  evidently  masculine. 

The  general  character  of  Durge  was  a mixture  of  the  male  and 
female  type.  When  between  twenty  and  thirty,  he  had  been 
examined  by  different  medical  men  in  Germany,  France,  and  Eng- 
land, and,  as  we  have  already  mentioned,  the  most  contradictory 
opinions  were  offered  upon  his  real  sex.  The  breasts  were  not 
much  developed,  and  there  was  no  distinct  mammary  glandular 
structure.  His  stature  was  small.  As  he  had  advanced  in  age,  his 
voice  had  become  more  firm  and  grave,  and  a slight  trace  of  beard 
had  appeared  ; but  his  head  and  face  presented  the  aspect  of  that  of 
an  old  woman.  His  neck  was  short,  and  the  thyroid  cartilage  did 
not  project  much  : his  cliest  was  fat  and  full.  During  the  last  few 
years  of  his  life  he  was  subject  to  epistaxis  and  hemorrhoids,  but  did 
not  present  any  trace  of  sanguineous  discharge  from  the  genital  organs 
— a phenomenon  which  was  alleged  to  have  manifested  itself  three 
times  during  his  twentieth  year. 

The  right  hemispheres  of  the  cerebrum  and  cerebellum,  particu- 
larly that  of  the  latter,  were  smaller  and  less  developed  than  the  left, 
and  the  left  side  of  the  occiput  was  externally  more  prominent  than 
the  right.  He  is  stated  by  Professor  Mayer  to  have  shown  a certain 
predilection  for  females,  without,  however,  feeling  any  sexual  desire. 


LATERAL  HERMAPHRODITISM. 


445 


2.  TESTICLE  ON  THE  LEFT,  AND  OVARY  ON  THE  RIGHT  SIDE. 

An  instance  of  malformation  of  the  reproductive  organs  minutely 
described  by  Maret,*  and  which  is  in  all  its  more  essential  anatomi- 
cal points  an  example  of  lateral  hermaphroditism,  may  be  included 
under  this  head. 

a.  The  subject  of  the  case,  Hubert  Jean  Pierre,  died  in  the 
hospital  at  Dijon  in  1767,  at  the  age  of  seventeen.  On  the  left 
side  a perfect  testicle  was  discovered,  with  its  usual  spermatic 
vessels,  vas  deferens,  and  vesicula  seminalis,  all  occupying  the 
natural  situation  in  which  they  are  jdaced  in  the  male  adult.  The 
vesicula  seminalis  contained  a fluid  of  the  colour  and  consistence  of 
semen.  On  the  right  side  an  oblong  cystic  tumour  was  found  lying 
in  the  iliac  fossa,  and  stretching  outwards  into  the  inguinal  region. 
On  opening  it  a quantity  of  reddish  limpid  fluid  escaped,  and  then 
the  solid  contents  of  the  tumour  were  seen  to  consist  of  a some- 
what flattened  body,  that  gave  off  from  the  upper  part  of  its  right 
side  a short  Fallopian  tube ; and  at  the  fimbriated  extremity  of 
this  tube  an  ovary  of  the  natural  size,  consistence,  and  figure,  was 
situated.  The  roundish-shaped  body  to  which  the  tube  was  at- 
tached was  about  an  inch  and  a half  in  its  greater,  and  an  inch  in 
its  smaller  diameter.  It  contained  in  its  centre  a small  cavity  con- 
tinuous with  that  of  the  tube — a circumstance  which,  along  with 
the  structure  of  its  walls,  left  little  doubt  that  the  body  itself  was 
|in  imperfectly  formed  uterus.  No  other  opening  except  that  of  the 
tube  could  be  traced  into  its  cavity.  Its  external  surface  was  at- 
tached to  the  ovary  by  a kind  of  ligament.  On  this  same  side  of 
the  body  (the  right)  there  existed  also  a vesicula  seminalis,  but 
smaller  and  more  shrivelled  than  that  on  the  left.  It  gave  off  a vas 
deferens,  which  became  gradually  smaller  as  it  was  traced  backwards, 
and  at  last  disappeared  altogether  without  being  connected  with  any 
structure  resembling  a testicle.  In  regard  to  the  external  organs  of 
generation,  the  penis  was  four  inches  long  and  imperforate,  but  in 
all  other  respects  perfectly  formed.  It  possessed  a corpus  spon- 
giosum, which  does  not  exist  in  the  female  clitoris.  On  raising  the 
penis,  it  was  observed  to  cover  a large  fissure,  the  sides  of  which 
resembled  the  labia  of  a female.  In  the  left  labium,  or  left  half  of 
the  scrotum,  the  testicle  already  alluded  to  was  placed,  but  there 
was  none  in  the  right.  When  the  labia  were  separated,  two  red 
spongy  bodies  were  seen,  resembling  the  nymphae  in  appearance,  and 
^ Mem.  de  V Acad,  dc  Dijon,  tom.  ii.  p.  157. 


446 


HERMAPHRODITISM. 


seemingly  consisting  of  the  sides  of  the  split  urethra.  Between 
these  bodies,  and  at  their  upper  part,  the  urethra  opened  as  in  the 
female  ; while  below  there  was  a very  narrow  aperture  covered  by 
a semilunar  membrane,  and  presenting  on  one  side  of  its  entrance  a 
small  excrescence  somewhat  resembling  in  figure  a caruncula  myr- 
tiformis.  This  orifice  led  into  a membranous  canal  or  cul-de-sac  an 
inch  in  depth  and  half-an-inch  in  diameter.  On  the  lower  part  of 
this  canal  the  verumontanum  and  orifices  of  the  seminal  ducts  of 
both  sides  were  discovered. 

During  life,  Pierre  had  been  considered  a male,  but  was  not 
known  to  have  shown  any  partiality  for  the  female  sex.  His  coun- 
tenance was  more  delicate  than  we  ordinarily  see  in  the  male  sex. 
There  was  no  beard  on  the  face ; the  larynx  was  not  enlarged  as  in 
man ; and  the  mammae,  each  of  which  was  furnished  with  a very 
large  areola,  were  of  a moderate  size  and  roundish  form.  The  con- 
figuration of  the  lower  part  of  the  body  was  more  decidedly  mas- 
culine, and  there  was  none  of  that  enlargement  of  the  buttocks  and 
projection  of  the  thighs,  from  the  increased  width  of  the  pelvis, 
which  is  observable  in  young  females. 

In  this  case  we  have  on  the  left  side  of  the  body  male  sexual 
organs,  consisting  of  a perfect  testicle,  vas  deferens,  and  vesicula 
seminalis.  On  the  right  side,  again,  we  have  a female  ovary  and 
Fallopian  tube  with  a rudimentary  uterus,  together  with  an  imper- 
fect male  vesicula  seminalis  and  vas  deferens. 

h.  Arnaud  mentions  a very  imperfect  form  of  lateral  hermaphro-^ 
ditism  as  having  been  recognised  by  M.  Boudou,  surgeon  to  the 
Hotel  Dieu  of  Paris,  on  the  person  of  a monk  who  died  in  that 
hospital  in  1726.  The  external  genital  parts  were  those  of  a hypo- 
spadiac  male.  In  one  of  the  halves  of  the  scrotum  a testicle  was 
found ; the  other  was  empty.  The  seminal  canals  and  vesiculce 
seminales  on  the  side  on  which  the  perfect  testicle  existed  were 
natural  in  their  course  and  situation.  Those  of  the  opposite  side 
lost  themselves  between  the  bladder  and  rectum  in  a small  body, 
wdiich,  in  M.  Boudou’s  opinion,  was  a shrunk  uterus,^ 

Among  the  preceding  cases  of  lateral  hermaphroditism  in  the 
human  subject,  there  are  five  in  wliich  the  left  side,  and  one  only  in 
which  the  right,  was  the  female.  In  the  last  instance,  quoted  from 
Boudou,  the  respective  sides  on  which  the  male  and  female  organs 
were  placed  are  not  stated  by  Arnaud. 


^ xVrnaud,  loc.  cit.  p.  283. 


TRANSVERSE  HERMAPHRODITISM. 


447 


B.  TRUE  TRANSVERSE  HERMAPHRODITISM. 

In  the  variety  of  hermaphroditic  malformation  which  Ave  have 
last  considered,  we  have  found  upon  the  same  individual  the  repro- 
ductive organs  of  one  side  disagreeing  in  their  sexual  type  from  those 
of  the  other.  In  the  present  division  we  have  a similar  sexual 
antagonism  following  a different  direction ; for  supposing  the  in- 
ternal sexual  apparatus  to  he  divided  from  the  external  by  a trans- 
verse line,  we  have,  in  transverse  hermaphroditism,  on  each  side  of 
this  partition,  organs  of  an  opposite  sexual  type ; in  other  Avords, 
the  organs  of  reproduction  (in  the  more  correct  sense  of  the  Avord), 
. or  the  internal  sexual  organs,  do  not,  in  the  present  species  of  her- 
maphroditism, correspond  in  type  Avith  the  organs  of  copulation,  or 
the  external  sexual  parts — a circumstance,  the  occasional  occurrence 
of  Avhich  tends  to  shoAV  that  these  tAvo  portions  of  the  generative 
apparatus  are  in  some  degree  independent  of  each  other  in  their 
normal  development  and  existence,  and  consequently  also  in  their 
abnormal  formations. 

Transverse  hermaphroditism  varies  in  its  chara’cter  according  to 
the  relative  positions  occupied  by  the  co-existing  male  and  female 
organs ; the  external  organs,  or  all  those  exterior  to  the  supposed 
transverse  line,  being  sometimes  female,  and  the  internal  male,  and 
vice  versa. 

1.  TRANSVERSE  HERMAPHRODITISM  WITH  THE  EXTERNAL  SEXUAL 
ORGANS  OF  THE  FEMALE  TYPE. 

In  the  cases  included  under  this  subdivision,  the  external  geni- 
tal organs  consist  of  a clitoris,  vagina,  and  uterus ; the  uterus  is 
often  rudimentary,  and  sometimes  altogether  absent  and  replaced  by 
the  male  vesiculae  seminales.  The  male  internal  organs  are  the  tes- 
ticles, generally  small  and  imperfectly  developed,  and  placed  either 
Avithin  or  without  the  abdomen,  Avith  vasa  deferentia  terminating  in 
the  uterus  and  vagina. 

This  variety  of  sexual  malformation  has  been  repeatedly  observed 
among  our  domestic  quadrupeds,  particularly  among  black  cattle. 
Mr.  John  Hunter,  in  an  essay  read  before  the  Eoyal  Society  in  1779, 
and  published  in  their  Transactions^  and  in  his  Observations  on  the 
Animal  Economy,  shoAved  that,  as  had  been  long  knoAvn  among 

^ Trans.  Royal  Society,  vol.  Ixix. 


448 


HERMAPHRODITISM. 


agriculturists,  when  among  black  cattle  the  cow  brings  forth  twin 
calves,  one  of  them  a male,  and  the  other  apparently  a female,  the 
male  is  a perfect  bull  calf,  but  the  female,  while  it  has  all  the  ex- 
ternal marks  of  a cow  calf,  as  the  teats  and  udder,  is  still,  with  a 
few  exceptions,  imperfectly  formed  in  its  internal  sexual  organs,  and 
very  generally  presents  a mixture  of  the  organs  of  the  two  sexes  in 
various  degrees.  Such  hermaphroditic  twin  cattle  have  long  been 
distinguished  in  this  country  under  the  name  of  free-inartins.  In 
some  exceptional  cases  only  have  they  been  observed  capable  of 
breeding ; and  generally  they  show  no  sexual  desire  for  the  bull,  or 
the  bull  for  them.  In  appearance  they  resemble  the  ox  or  spayed 
heifer,  and  have  a similar  or  still  greater  disposition  to  become  fat 
under  the  use  of  good  food. 

In  the  paper  to  which  we  have  referred,  Mr.  Hunter  has  de- 
scribed the  dissection  of  three  free-martins ; and  one  of  these  seems 
to  belong  to  our  present  division  of  female  transverse  hermaphro- 
ditism. The  clitoris  and  external  parts  appear  to  have  been  strictly 
of  the  female  type,  and  there  was  a small  udder  with  four  teats. 
The  vagina  terminated  in  a blind  end  a little  beyond  the  opening 
of  the  urethra,  and  from  this  point  the  vagina  and  uterus  were  im- 
pervious. The  uterus  at  its  superior  part  divided  into  two  horns, 
and  at  the  termination  of  tliese  horns,  not  ovaria,  but  bodies  re- 
sembling the  male  testicles,  were  found.  These  bodies  had  not  a 
perfect  internal  structure  like  that  of  testicles,  but  resembled  these 
organs  in  so  far  that — 15/,  they  were  nearly  as  large  as  the  male 
testes,  and  much  larger  than  the  female  ovaries  ; 2(1,  they  were  sup- 
plied with  tortuous  spermatic  arteries  like  those  of  the  bull  or  rigdil ; 
and  3f/,  cremaster  muscles  passed  up  to  them,  as  in  rigdils,  from  the 
abdominal  rings.  There  were  two  small  vesiculse  seminales  placed 
behind,  between  the  bladder  and  uterus,  with  their  ducts  opening 
into  the  vagina.  Nothing,  according  to  Mr.  Hunter,  similar  to  the 
vasa  deferehtia  was  present ; but  Gurlt  is  inclined  to  believe  that 
the  parts  which  Mr.  Hunter  has  described  as  the  horns  of  the  uterus 
were  really  the  deferent  vessels. 

Professor  Gurlt  ^ has  himself  given,  from  a preparation  in  the 
Museum  of  the  Berlin  Veterinary  School,  the  accompanying  sketch 
of  the  malformed  sexual  organs  of  a five-year-old  free-martin  (Fig.  8), 
which  presents  to  us  an  illustration  of  Mr.  Hunter’s  supposed  mis- 
take, at  the  same  that  it  affords  a well-marked  example  of  transverse 
hermaphroditism.  The  detail  of  the  anatomical  peculiarities  of  the 

^ Lchrbuch  dcr  Pathol.  Anat.  der  Saug.  Th.  Bd.  ii.  s.  186. 


TKANSVERSE  HERMAPHRODITISM. 


449 


case  has  been  unfortunately  omitted  by  the  author,  but  from  the 
short  explanations  appended  to  the  drawing,  it  appears  that  the 
clitoris,  ft,  and  external  pudenda, 

1),  were  perfectly  feminine,  and 
that  the  vagina,  short  and  funnel- 
shaped,  terminated  at  its  supe- 
rior contracted  extremity  in  two 
vasa  deferentia,  ccc,  which  were 
carried  upwards  in  a duplicature 
of  peritoneum,  d d,  resembling 
the  broad  ligament,  until  they 
joined  the  unrolled  and  length- 
ened epididymes,  e e,  of  two  small 
testicles,  / /,  placed  in  the  posi- 
tion of  the  ovaries.  Near  the 
junction  of  the  vagina  and  vasa 
deferentia,  bodies  resembling  the 
male  vesiculae  seminales,  g g,  and 
Cowper’s  glands,  h h,  were  situ- 
ated, and  the  urethral  canal, 
opened  into  the  vagina,  and  was 
shorter  than  it  usually  is  in  the 
cow. 

We  have  found  upon  a free- 
martin  cow  a state  of  the  sexual 
apparatus  very  much  resembling 
that  figured  in  the  above  case  by 
Professor  Gurlt.  The  two  vasa 
deferentia,  as  they  ran  in  the 
duplicature  of  the  peritoneum, 
had  very  much  the  appearance  and  shape  of  an  imperfectly  deve- 
loped uterus.  The  vesiculaB  seminales  were  large ; the  vasa  defer- 
entia were  quite  impervious  throughout  their  whole  course  ; and 
the  bodies  placed  at  their  abdominal  extremities  were  large,  but  of 
so  indeterminate  a structure  as  not  to  enable  us  to  pronounce  them 
to  be  either  true  testicles  or  ovaries. 

M.  Geoffrey  St.  Hilaire  published  in  1834  a very  distinct  case 
of  a hermaphroditic  goat  which  had  two  male  testicles  and  epidi- 
dymes with  a two-horned  uterus  and  female  external  parts.*  M. 

^ Nouv.  Ann.  du  Museum  d'Hist.  Nat.  tom.  ii.  p.  141. 


450 


HERMAPHRODITISM. 


Isidore  St.  Hilaire i mentions  a nearly  analogous  case  in  the  same 
animal,  and  quotes  a third  from  Bomare  which  was  observed  upon 
a deer.^ 

To  the  present  division  of  transverse  hermaphroditic  malforma- 
tion with  external  female  and  internal  male  organs,  we  may  pro- 
bably also  refer  the  case  of  the  hermaphrodite  dog  detailed  by  Sir 
E.  Home,®  and  three  instances  in  the  sheep  described  by  Buysch,^ 
Herholdt,®  and  Gurlt.®  In  all  these  instances,  imperfectly  developed 
testicles  were  situated  either  within  the  abdomen  or  without  it  upon 
the  udder,  at  the  same  time  that  the  external  parts  exhibited  in  a 
more  or  less  marked  degree  the  peculiarities  of  the  female  sex  ; the 
vagina  was,  however,  narrower,  and  the  clitoris  more  developed  than 
in  the  perfectly-formed  female  ; and  in  the  dog  mentioned  by  Home 
this  latter  organ  was  very  large,  being  three-quarters  of  an  inch 
long,  and  half-an-inch  broad,  but  still  it  could  not  properly  be  con- 
sidered as  an  imperfect  penis,  since  the  bone,  which  forms  the  dis- 
tinguishing mark  of  that  organ  in  the  dog,  was  wanting. 

Few  well-marked  instances  of  transverse  hermaphroditism  with 
external  female  organs,  have  been  hitherto  described  as  observed  in 
the  human  subject,  unless  we  regard  as  an  approach  to  it  the 
numerous  cases,  already  referred  to,  of  spurious  hermaphroditic 
malformation  in  the  male  from  hypospadiac  division  of  the  urethra, 
scrotum,  and  perineum. 

a.  In  his  essay  on  hermaphroditism,  however,  Steghlehner^  has 
detailed  at  great  length  the  particulars  of  a case  belonging  to  the 
present  variety,  which  he  met  with  on  the  body  of  a woman  who 
died  of  phthisis  at  the  age  of  twenty-three.  The  external  sexual 
organs  were  all  of  the  female  type,  and  in  general  well  formed, 
though  the  clitoris  and  nymphse  were  perhaps  smaller  than  natural, 
and  the  orificium  vaginae  w^as  rather  contracted  and  half  shut  up  by 
a hymen.  The  fossa  navicularis  was  very  distinct,  and  the  vagina 
normally  situated,  but  extremely  short  and  narrow.  Its  internal 
surface  presented  an  appearance  of  transverse  and  longitudinal  rugae, 
but  its  upper  extremity  formed  a blind  sac,  and  no  traces  could  be 
found  beyond  it  of  the  uterus,  nor  indeed  any  vestiges  whatever  of 

^ Histoire  des  Anomalies,  tom.  ii.  p.  128. 

2 Journ.  dc  Phys.  tom.  vi.  p.  501. 

2 Phil.  Trans,  for  1795,  p.  157  ; Comjj.  Anat.  iii.  323. 

^ Thesaur.  Anat.  viii.  n.  c.  iii.  tab.  115. 

® Viborg  s Sammlungs  fur  Thicrartze,  1797,  s.  25. 

® Lchrhuch,  etc.,  Bd.  ii.  s.  186  tab.  ix.  2,  and  xxii.  s.  2. 

^ Tract,  de  Hermaphr.  naturd,  p.  120. 


TRANSVERSE  HERMAPHRODITISM. 


451 


the  other  internal  female  organs,  the  ovaries  and  Fallopian  tubes. 
On  more  minute  examination,  a testicle  with  its  spermatic  cord  was 
found  in  each  inguinal  region,  placed  outside  the  external  ring,  and 
surrounded  with  their  cremaster  muscles  and  vaginal  coats.  The 
testicles  were  flaccid  and  small,  but  their  internal  structure  and  that 
of  their  epididymes  was  natural ; and  the  slender  pervious  vasa 
deferentia  arising  from  them  entered  the  abdomen,  descended  into 
the  pelvis,  and  were  joined  behind  the  urinary  bladder  by  two 
vesiculse  seminales  of  considerable  size.  Their  commmn  ejaculatory 
ducts  opened  into  the  vagina.  The  form  of  the  thorax  and  pelvis, 
and  of  the  body  in  general,  was  feminine ; and  the  mammsB  and 
nipples  were  well  developed,  but  the  larynx  Avas  rather  more  pro- 
tuberant than  in  females,  and  the  voice  approached  in  tone  to  that 
of  a man.  There  had  never  been  any  menstrual  discharge,  but  the 
periodical  molimina  indicative  of  its  appearance  were  said  to  have 
been  observed  regularly.  There  Avere  some  hemorrhoidal  tumours 
situated  around  the  anus. 

h.  If  possible,  a still  more  perfect  example  of  the  present  variety 
of  transverse  hermaphroditism  in  the  human  subject  Avas  some  years 
ago  observed  at  Naples.  The  malformation  occurred  in  the  person  of 
an  individual,  Maria  E.  Arsano,  Avho  died  at  the  age  of  eighty  in  one 
of  the  pauper  charities  at  Naples,  and  who  had  passed  through  life  as 
a female,  and  been  married  as  such.  No  suspicion  of  the  malforma- 
tion existed  during  life,  and  it  Avas  only  accidentally  discovered  Avhen 
preparing  the  dead  body  for  demonstration  in  the  anatomical  theatre 
of  Professor  Ricco,  avIio  afterwards  carefully  dissected  the  malformed 
parts  in  company  Avith  Professors  Sorrentino  and  Grosetti.  We  have 
taken  the  following  account  and  sketches  from  Ricco’s  published 
description  of  the  case.^ 

The  external  organs  of  generation  Avere  those  of  the  female  in 
their  natural  or  normal  state,  consisting  of  the  mons  veneris,  Avith  a 
scanty  quantity  of  hair  (Fig.  9,  a)  ; of  the  labia  externa  (Figs.  9 and 
10,  hh)  naturally  formed,  and  the  nymphse  (Figs.  9 and  10,  c?  d) ; of 
the  clitoris  (Figs.  9 and  1 0,  c),  Avhich  Avas  perfectly  imperforate,  and 
of  the  ordinary  size  of  the  same  organ  in  the  adult  female ; of  the 
orifice  of  the  urethra  (Figs.  9 and  1 0,  e)  situated  beloAV  the  clitoris ; 
and  of  the  os  vaginae  (Figs.  9 and  10,/),  Avhich  Avas  of  the  usual  size 
and  diameter.  Altogether,  the  aperture  of  the  vulva  Avas  natural. 
The  canal  of  the  urethra  was  of  the  usual  length,  as  seen  at  u in  the 
section  of  the  pelvis  represented  in  Figure  10,  in  Avhich  s marks  the 
^ Cenno  Siorico  su  di  un  Xcutro-Uovio,  pp,  5,  7. 


452 


HERMAPHRODITISM. 


divided  symphysis  pubis,  and  jp  the  peritoneum.  The  os  vaginae 
showed  no  vestiges  of  the  membrane  of  the  hymen,  or,  in  other 


Fig.  9. 

■words,  was  without  carunculae  myrtiformes.  The  canal  of  the  vagina 
(Fig.  10,  i)  was  about  two  inches  long,  but  without  rugae,  and  it 
terminated  internally  in  a completely  blind  extremity  or  cul-de-sac. 


The  uterus  was  entirely  wanting,  as  were  also  the  Fallopian  tubes 
and  uterine  ligaments. 

The  internal  organs  of  reproduction  were,  on  the  other  hand, 
completely  male.  The  two  testicles  (Fig.  9,  g g)  were  situated  in  the 


PJCCO’S  TRANSVERSE  HERMAPHRODITE. 


453 


region  of  the  pubis,  and  were  scarcely  clear  of  the  inguinal  rings. 
They  were  of  the  usual  ovoid  figure,  and  natural  in  size.  They  had 
internally  the  structure  of  the  tubuli  seminiferi,  but  it  was  not  well 
developed.  The  spermatic  cords  were  quite  normal  both  in  regard 
to  their  composition  and  the  origin  and  course  of  their  blood  vessels. 
The  right  spermatic  artery  (Fig.  9,  /)  arose,  as  usual,  from  the  renal, 
and  the  corresponding  vein  m,  after  forming  the  pampiniform  plexus, 
TCj  opened  into  the  vena  cava  inferior ; while  on  the  left  side  the 
artery,  Z,  arose  from  the  aorta,  and  the  vein,  m,  terminated  in  the  left 
emulgent.  The  epididymes  of  the  testes  were  also  of  the  usual  vermi- 
form figure,  and  the  corresponding  vasa  deferentia  (Figs.  9 and  10, 
li  h),  coursed  towards  their  vesiculse  seminales  (Fig.  10,  j),  and  ter- 
minated in  an  attenuated  membranous  expansion  without  any  ex- 
ternal aperture  or  ducti  ejaculatorii.  The  vesiculae  seminales  (see 
the  left  one,  y,  in  Fig.  10)  were  placed  between  the  urinary  bladder, 
0,  and  rectum,  r ; they  were  smaller  and  more  shrunk  than  those  of 
the  adult  male,  though  certainly  they  preserved  their  naturally  ob- 
long form.  Their  internal  hollow  or  tubular  structure  was  indistinct. 
The  prostate  gland  was  not  present.  The  urinary  bladder,  o,  and 
ureters,  n n,  the  rectum  r,  and  the  other  intestinal  viscera,  with  the 
abdominal  blood-vessels  {s,  the  aorta,  Z,  the  vena  cava.  Fig.  9),  seem 
to  have  been  all  quite  natural. 

The  head  of  the  above  individual  was  of  the  usual  size,  the  neck 
long,  and  the  stature  ordinary.  The  periphery  of  the  thorax  was  so 
expanded  as  almost  to  equal  that  of  the  male,  notwithstanding  the 
presence  of  well-pronounced  mammae.  The  face,  although  entirely 
free  from  hair,  had  yet  neither  the  expression  of  that  of  a female 
nor  of  a male,  but  showed  more  of  that  mixed  character  which  is 
seen  in  the  eunuch.  The  pelvis  was  altogether  that  of  a male  in  its 
form  and  dimensions,  and  the  limbs  were  perfectly  masculine.  Ac- 
cording to  information  collected  after  death,  the  voice  was  deep,  and 
the  temperament  strong  and  firm.  Though  there  was  never  any 
menstruation,  yet,  from  being  constantly  employed  in  domestic  occu- 
pation, the  mental  character  was  feminine,  and  the  married  state  had 
been  willingly  entered  into. 

2.  TRANSVERSE  HERMAPHRODITISIM  WITH  THE  EXTERNAL  SEXUAL 
ORGANS  OF  THE  MALE  TYPE. 

The  male  organs  that  are  present  in  this  subdivision,  consist  of 
the  penis,  which  is  provided  with  a regularly-formed  prepuce,  glaiis^ 


454 


HERMAPHRODITISM. 


corpora  cavernosa,  and  corpus  spongiosum,  with  the  urethra  perfo- 
rating it,  and  of  the  prostate  gland,  verumontanum,  etc.  The  co- 
existing female  organs  are  the  ovaries,  the  Fallopian  tubes  with  their 
infundibula,  and  the  uterus. 

We  are  not  aware  of  any  recorded  instances  of  this  variety  of 
hermaphroditic  malformation  among  the  lower  animals.  We  have 
already,  under  the  head  of  spurious  hermaphroditism  in  the  female, 
from  enlargement  of  the  clitoris,  etc.,  mentioned  several  cases,  in 
which,  from  excessive  development,  the  external  organs  in  women  had 
assumed  some  of  the  characters  of  the  corresponding  parts  in  man ; 
but  the  two  following  cases  described  by  Professor  Eschricht  of 
Copenhagen,  and  Bouillaud  of  Paris,  present  instances  of  malforma- 
tion in  which  the  more  exterior  sexual  organs  were  all  formed  upon 
the  male,  and  the  internal  upon  the  female  type. 

a.  The  subject  of  the  case  described  by  Eschricht^  was  a twin 
child  that  died  very  shortly  after  birth,  and  in  whom  the  external 
sexual  organs  were  of  the  male  type,  and  the  internal  female.  The 
penis  (Fig.  11,  and  scrotum,  h,  were  well  devel(jped,  but  the  usual 
raph^  seen  upon  the  latter  was  absent.  The  urethral  canal  of  the 
glans  and  body  of  the  penis  was  pervious  throughout,  and  admitted 
of  a sound  being  easily  passed  into  the  bladder.  The  glans  was 
remarkably  thin  and  slender.  The  prepuce  could  be  easily  pushed 
back.  No  testicles  could  be  felt  in  the  scrotum,  and  internally  there 
was  a uterus  with  Fallopian  tubes  and  ovaries.  The  uterus,  c,  was 
about  an  inch  in  length,  and  had  the  general  form  presented  by  this 
organ  in  female  infants.  It  contained  a cavity  marked  with  rugse, 
but  had  no  orifice  interiorly,  nor  any  vagina  attached  to  it.  Its 
blind  or  imperforate  neck  was  firmly  attached  to  the  posterior  walls 
of  the  urinary  bladder,  g,  while  its  fundus  was  directed  very  ob- 
liquely downwards  and  over  to  the  left  side.  From  the  left  side  of 
the  fundus  of  the  uterus  a twisted  Fallopian  tube,  d,  proceeded, 
having  well-developed  fimbrios,  e,  at  its  abdominal  extremity,  and 
the  broad  ligament  or  fold  of  peritoneum  along  which  it  ran  con- 
tained an  oblong  soft  body,  i,  which  Eschricht  considered  as  distinctly 
an  ovary,  and  a round  ligament  that  took  its  course  through  the 
inguinal  canal  of  the  same  side.  On  the  right  side  an  ovary,  Jc,  and 
Fallopian  tube,  /,  were  likewise  discovered,  but  they  were  displaced 
and  separated  from  the  body  of  the  uterus.  The  ovary  lay  in  the 
iliac  region,  and  above  it  and  towards  its  outer  side  was  placed  the 
fimbriated  extremity  of  the  corresponding  Fallopian  tube.  The 
^ Muller’s  Archiv  fur  Anatomic,  etc.,  1836,  Heft  ii. 


ESCIirJCHT’S  TRANSVERSE  HERMAPHRODITE. 


455 


tube  presented  towards  this  extremity  a vesicular  swelling  of  the 
size  of  a small  pea,  which  admitted  of  being  inflated  and  filled  with 
quicksilver  through  a small  opening  between  the  fimbriae.  Below 
this  it  was  impervious,  and  apparently  diverged  off  into  two  pro- 
longations, one  of  which  (the  round  ligament)  passed  down  into  the 


Fig.  11. 

inguinal  canal,  and  the  other  crossed  over  with  a fold  of  peritoneum 
to  where  the  rectum  and  urinary  bladder  were  preternaturally  con- 
nected together.  Professor  Jacobson  suggested  that  this  latter  part 
was  a rudiment  of  the  right  half  or  horn  of  tlie  uterus.  It  may 
perhaps,  however,  be  more  properly  regarded  as  the  commencement 
of  the  right  Fallopian  tube,  and  in  this  case  it  would,  if  continued 
onwards,  have  been  joined  to  the  neck  of  the  uterus  — an  arrange- 
ment which  would  be  quite  in  accordance  with  the  usual  deep  and 
displaced  origin  of  one  of  the  tubes  in  instances  of  congenital  obli- 
quity of  the  uterus. 

The  child  was  malformed  in  other  respects  also.  The  anus  was 
imperforate,  and  the  rectum,  n,  opened  into  the  urinary  bladder, 
which  was  very  contracted.  The  kidneys,  m,  were  irregularly  formed, 
and  lay  near  the  promontory  of  the  sacrum.  There  was  an  accessory 
spleen,  and  the  formation  of  the  heart  and  large  vessels  was  abnor- 
mal. The  other  twin  child  was  well  formed  and  lived. 

h.  The  case  of  transverse  hermaphroditism  observed  by  Bouil- 
85 


456 


HERMAPHRODITISM. 


laud  ^ was  even  still  better  marked  than  that  of  Eschricht.  Valmont, 
the  individual  who  was  the  subject  of  it,  died  in  one  of  the  hospitals 
of  Paris  of  the  epidemic  cholera.  He  was  a hatter  by  trade,  and 
had  been  married  as  a male.  No  further  particulars  of  his  history 
or  habits  could  be  obtained.  The  following  was  found  by  MM. 
Manec  and  Bouillaud  to  be  the  state  of  the  external  and  internal 
sexual  organs. 

Externally  there  was  a penis  (Fig.  2)  of  medium  size,  terminat- 
ing in  a regularly -formed  glans, 
rt,  and  furnished  with  a pre- 
puce, h. 

The  urethra  (Fig.  13,  h b) 
opened  on  the  inferior  side  of 
the  glans  (Figs.  12  and  13,  a). 
In  its  course  from  this  point 
backwards  to  the  bladder,  it  per- 
fectly resembled  the  urethra  of 
the  male,  and  was  surrounded 
at  its  origin  by  a well-formed 
2)rostate  gland  (Fig.  13,  k k). 
Cowper’s  glands  were  also  pre- 
sent (Fig.  12,  d).  The  veru- 
montanum  or  caput  gallinaginis  was  distinct,  as  well  as  the  orifices 
of  the  prostatic  follicles  ; but  the  usual  openings  of  the  seminal 
canals  could  not  be  found.  The  corpus  spongiosum  urethrae  (Fig. 
12,  g)  and  the  corpora  cavernosa  (Fig.  13,  m m)  were  as  well 
developed  as  in  the  perfect  male  subject.  The  scrotum  Avas  small, 
and  did  not  contain  any  testicles ; it  presented  on  its  middle  a line 
or  raphe  extending  from  the  prepuce  to  the  anus,  and  which  was 
harder  and  better  marked  than  it  usually  is  upon  male  subjects. 
The  various  muscles  of  the  male  perineum  (Fig.  12,  c c)  were  present, 
and  very  perfectly  formed.  The  constrictores  urinae  muscles,  e, 
Avere  particularly  long  and  thick. 

In  the  cavity  of  the  jAelvis,  tAvo  ovaries  (Fig.  13,  d d),  similar  in 
form  and  structure,  according  to  M.  Manec,  to  those  of  a girl  of' 
fifteen  or  sixteen  years  of  age,  or,  to  adopt  M.  Bouillaud's  state- 
ment, tAv^o  bodies  in  some  sort  fibrous,  and  i:)erhaps  intermediate  in 
their  structure  betAveen  ovaries  and  testicles,  AA'ere  found,  along  Avith 
two  Fallopian  tubes  (Fig.  1 3,  g g),  having  each  a fimbriated  extremity 

^ Journ.  Hcbdom.  de  Med.,  tom.  x.  p.  466.  “Exposition  Raisonnee  d’un  cas 
de  nouvelle  et  singuliere  variete  d’hermapliroditisme  observee  chez  I’homme.” 


bouillaud’s  case. 


457 


at  one  end,  and  opening  by  the  other  into  the  cavity  of  a uterus,  /i, 
which  occupied  the  usual  situation  of  that  organ  in  the  female,  and 
opened  inferiorly  into  a kind 
of  vagina,  e.  The  internal  sur- 
face of  the  uterus  showed  the 
usual  arborescent  wrinkles  of 
this  organ  in  the  unimpreg- 
nated state  ; the  os  tincae  was 
regularly  formed ; the  vagina 
was  about  two  inches  long, 
and  of  medium  size,  and  pre- 
sented internally  numerous 
ridges,  such  as  are  met  with  in 
virgins.  This  canal,  when  op- 
posite the  neck  of  the  bladder 
at  /,  became  much  contracted, 
and  was  continued  downwards 
in  the  form  of  a small  tube  to 
the  membranous  portion  of 
the  urethra,  into  which  it  en- 
tered by  a narrow  orifice.  The 
broad  ligaments  of  the  uterus 
were  normally  formed ; the 
round  ligaments  passed  through 
the  inguinal  canal,  accompanied, 
each,  by  an  artery  larger  than  that  of  the  corresponding  one  in  the 
female  sex. 

The  external  appearance  and  form  of  Valmont  are  described  by 
M.  Bouillaud  as  having  been  intermediate  between  those  of  the 
male  and  female  sex.  The  stature  was  short ; the  mammary  glands 
and  nipples  were  well  developed  ; the  face  was  bearded ; but  the 
general  physiognomy  was  still  delicate.  The  body  was  fat ; the 
hands  and  feet  Avere  small ; the  pelvis  was  shallow ; and  the 
haunches  were  wider  than  in  a well-formed  man. 

C.  TRUE  DOUBLE  OR  VERTICAL  HERMAPHRODITISM. 

In  the  tAvo  divisions  or  orders  of  true  hermaphroditism  Avhich 
have  been  already  considered — the  lateral  and  the  transverse — Ave 
have  seen  re-united  upon  the  body  of  the  same  individual  more  or 
fewer  of  the  organs  of  the  tAVO  sexes,  but  so  arranged  as  not 


458 


HERMAPHRODITISM. 


nec-^issarily  at  least  to  present  the  occurrence  of  actual  duplicity  in 
any  of  the  corresponding  male  and  female  parts.  In  both  lateral 
and  transverse  hermaphroditism,  the  type  of  the  sexual  apparatus  is 
in  fact  single^  in  so  far  that  it  consists  in  almost  all  cases  in  the 
presence,  at  one  part,  of  an  organ  or  organs  differing  in  sexual 
type  from  those  that  are  present  at  other  parts,  without  there 
necessarily  co-existing  at  any  one  point  the  two  corresponding  male 
and  female  organs.  In  the  present  or  third  variety,  however,  of 
true  hermaphroditism,  we  come  to  a tendency  to  actual  sexual 
duplicity,  in  the  co-existence  of  two  or  more  of  the  analogous  organs 
of  tlie  two  sexes  upon  the  same  side,  or  in  the  same  vertical  line  of 
the  body.  At  the  malformed  point  or  points  the  sexual  apparatus 
is  double,  and  one  part  male,  the  other  part  female,  in  type.  For, 
supposing  we  viewed,  either  from  before  or  behind,  the  reproductive 
organs  belonging  to  the  two  sexes  all  stretched  out  upon  the  same 
plane,  so  that  their  corresponding  organs  should  be  exactly  super- 
imposed upon  one  another — as  the  two  female  ovaries  upon  the  two 
male  testicles,  the  Fallopian  tubes  upon  the  vasa  deferentia,  the 
uterus  upon  the  vesiculse  seminales  and  prostate  gland,  etc. — we 
find  in  vertical  or  double  hermaphroditism  more  or  fewer  of  those 
analogous  organs  of  the  two  sexes  that  w^ere  thus  placed  upon  one 
another,  and  that  consequently  lay  in  the  same  vertical  line,  or 
upon  the  same  side  of  the  body,  co-existing  together  at  the  same 
time  upon  the  same  individual. 

Double,  vertical,  or  complex  hermaphroditism,  differs  much  in 
variety  and  degree,  in  different  cases,  from  the  imperfect  repetition  of 
two  only  of  the  corresponding  organs  of  the  male  and  female  upon 
the  same  body,  to  the  re-union  or  co-existence  of  almost  all  the 
analogous  internal  genital  organs  of  both  sexes  upon  one  individual. 

For  the  purpose  of  contrasting  and  collecting  together  as  much 
as  possible  the  more  analogous  cases,  v^e  shall  arrange  the  instances 
of  double  hermaphroditism  under  three  genera  or  divisions  ; theAb’s^ 
including  cases  in  which  there  co-existed  a female  uterus  and  male 
vesiculse  serninalis,  with  a general  female  type  ; the  second,  those  in 
which  a female  uterus,  occasionally  provided  with  Fallopian  tubes, 
was  added  to  an  organisation  that  was  in  other  respects  essentially 
male ; and  the  third  comprehending  all  examples  in  which  ovaries 
and  testicles  are  alleged  to  have  been  repeated  together  upon  one  or 
both  sides  of  the  body.  Other  divisions  of  double  hermaphroditism 
may  become  necessary  under  the  accumulation  of  new  varieties  of 
cases,  but  we  believe  it  will  be  possible  to  airange  all  the  instances 


DOUBLE  HERMAPHRODITISM. 


459 


hitherto  recorded  under  one  or  other  of  the  above  divisions.  In  classi- 
fying and  describing  these  instances,  vve  shall  in  the  meanwhile  offer 
no  observations  on  the  probable  anatomical  mistakes  that  have  been 
committed  in  the  examination  of  individual  cases ; and  we  shall 
describe  the  various  malformed  parts  according  to  the  designations 
usually  given  to  them  in  normal  anatomy,  and  by  the  authors  who 
have  described  the  cases.  We  reserve  the  true  anatomical  and  mor- 
phological value  of  the  different  structures  named  and  involved,  for 
special  consideration  under  a separate  and  future  chapter,  where  we 
shall  endeavour  to  show  the  numerous  sources  of  error  with  which 
the  observation  of  individual  examples  and  varieties  of  complex 
hermaphroditism  is  beset. 

1.  MALE  VESCICUL.E  SEMIN  ALES,  ETC.,  SUPERADDED  TO  ORGANS  OF 
A FEMALE  SEXUAL  TYPE. 

In  this  first  genus  or  division  of  double  hermaphroditism,  we 
find  two  female  ovaries,  or  bodies  resembling  ovaries,  and  an 
imperfect  uterus,  co-existing  with  two  male  vesiculie  seminales, 
which  are  occasionally  accompanied,  also,  with  rudiments  of  the 
vasa  deferentia.  One  of  the  free-martins  described  by  Mr.  Hunter  ^ 
is  referable  to  this  variety  of  double  hermaphroditism.  The  ex- 
ternal genital  organs  and  mammae  resembled  those  of  the  cow,  but 
were  smaller  in  size.  The  vagina,  beyond  the  opening  of  the 
urethra  into  it,  was,  with  the  uterus  itself,  impervious.  The  imper- 
fect uterus  divided  into  two  horns,  at  the  end  of  which  were  the 
ovaria.  On  each  side  of  the  uterus  there  was  an  interrupted  vas 
deferens,  broken  off  in  several  places ; and  between  the  bladder 
and  vagina  these  vasa  deferentia  terminated  in  two  vesiculse  semi- 
nales. The  ducts  from  the  vesiculae  and  the  vasa  deferentia  opened 
into  the  vagina.  In  this  instance  we  have  all  the  female  organs 
present,  but  imperfect  in  their  development ; and  at  the  same  time 
there  is  superadded  to  them  a tubular  structure,  formed,  according 
to  Mr.  Hunter’s  opinion,  of  the  male  vesiculse  seminales  and  vasa 
deferentia. 

In  a free-martin  cow,  which  I had  an  opportunity  of  dissecting, 
an  arrangement  of  sexual  parts  very  similar  to  that  described  in  the 
preceding  case  was  found.  The  uterus,  however,  though  small,  w*as 
pervious  for  a distance  of  some  inches  above  the  vagina ; and  at  the 
abdominal  end  of  each  blind  Fallopian  tube  there  was  a dilated  sac 
^ See  An.  Econ.  p.  64.  Mr.  Well’s  Free-martin. 


460 


IIEEMAPHEODITISM. 


of  considerable  size,  lined  by  peritoneum,  and  opening  into  tlie 
abdominal  cavity  by  a small  orifice.  These  sacs  we  considered  as 
abortive  attempts  at  the  formation  of  the  fimbriated  extremities. 
Imperfect  bodies,  which  we  considered  as  ovaries,  were  placed  in 
their  normal  situation  near  the  cavities  which  we  mention.  They 
were  small  in  size,  and  of  an  oblong  shape.  On  a section  being 
made  of  them,  they  showed  internally  a kind  of  dense  homogeneous 
yellow  tissue,  dotted  or  crossed  with  strongly  marked  white  lines. 
The  male  vasa  deferentia  could  be  traced  along  each  side  of  the 
uterus  in  the  form  of  broken  dense  cords.  The  vesiculie  seminales 
were  large  and  partially  hollow,  and  near  them  on  each  side  there 
was  an  oblong  body  of  considerable  size,  having  the  appearance  of 
Cowper’s  glands.  The  tubes  from  them,  and  from  the  vesciculse 
seminales,  opened  near  the  os  tincse  into  a vagina  of  nearly  the 
usual  size. 

2.  AN  IMPERFECT  FEMALE  UTERUS,  ETC.,  SUPERADDED  TO  A SEXUAL 
ORGANISATION  ESSENTIALLY  MALE. 

In  the  cases  included  under  this  second  division  of  double  or 
vertical  hermaphroditism,  there  exist  a male  testicle  or  testicles, 
vasa  deferentia,  and  vesiculse  seminales,  along  with  a female  uterus. 
The  uterus  occupies  its  normal  situation  between  the  bladder  and 
rectum.  It  is  sometimes  defectively  developed,  and  of  a membranous 
structure  ; and  occasionally  it  is  not  provided  with  Fallopian  tubes, 
or,  in  the  quadruped,  with  cornua.  The  cavity  of  the  uterus  com- 
municates with  a vagina  that  either  opens  in  its  usual  situation 
externally,  or,  as  happens  more  frequently,  joins  the  male  urethra. 
In  some  cases  the  vagina  is  wanting,  and  the  uterus  opens  directly 
into  the  canal  of  the  urethra. 

Several  cases  of  sexual  malformation  in  the  ram,  goat,  and  dog, 
referable  to  this  variety  of  double  hermaphroditism,  have  been  de- 
scribed by  different  authors ; and  various  analogous  instances  have 
now  also  been  observed  in  the  human  subject. 

In  a lamb  described  and  delineated  by  Mr.  Thcma?,'  all  the 
external  parts  were  male,  but  the  scrotum  was  divided  or  hypo- 
spadiac.  Internally  there  were  two  perfect  male  testicles  in  the 
situation  of  the  ovaries,  with  their  epididymes,  vasa  deferentia,  and 
vesiculse  seminales;  and  a well- formed  two-horned  uterus  furnished 

^ London  Med.  and  Phys.  Journ.,  vol.  ii.  1799,  p.  1 ; with  a good  drawing  of 
the  malformed  organs  of  generation. 


DOUBLE  HERMAPHRODITISM. 


461 


with  its  usual  ligaments,  and  with  Fallopian  tubes  that  ran  up  and 
terminated  in  a tortuous  convoluted  manner  upon  the  testicles. 
The  body  of  the  uterus  possessed  the  common  rugose  structure,  but 
the  horns  were  lined  by  a smooth  membrane,  without  their  usual 
glandular  bodies  internally.  At  the  anterior  extremity  of  the  fundus 
uteri,  a thick  semilunar  valve,  which  seemed  to  correspond  to  the 
os  tincae,  passed  across,  and  hardly  allowed  a fine  probe  to  be 
entered  over  its  upper  edge.  The  vagina  scarcely  existed,  and 
formed  only  a short  smooth  pouch,  terminating  below  in  a cul-de- 
sac.  The  male  vesiculae  seminales  and  vasa  deferentia  entered  the 
male  urethra  in  their  normal  situation  at  the  caput  gallinaginis. 

Gurlt  ^ has  described  and  delineated  the  sexual  parts  of  a goat, 
in  which  all  the  internal  male  genital  organs  were  found  with  the 
exception  of  Cowper’s  glands  (Fig.  14).  There  was  also  present 
a uterus,  e,  provided  with  long  but  narrow  and  curved  cornua,  / /, 
that  accompanied  the  vasa  deferentia  and  testicles  through  the 
abdominal  rings,  and  ended  blind  at  the  epididymes.  The  testicles 
lay  externally  upon  the  udder,  which  was  of  considerable  size.  The 
scrotum  was  absent ; the  penis,  g,  was  short,  tortuous,  and  imper- 
forate ; and  there  was  a fissure  in  the  perineum  into  which  the 
urethra,  /i,  opened. 

Stellati*  has  recorded  an  analogous  case  in  the  same  animal. 
The  male  sexual  organs  were  not  entirely  complete,  and  there  were 
superadded  to  them  a female  vagina  and  an  imperfectly-developed 
uterus,  the  Fallopian  tubes  of  which  ran  towards  the  inguinal  rings, 
and  terminated  with  them  upon -the  epididymes  of  the  testicles. 

Another  instance  of  hermaphroditic  malformation  in  the  goat, 
detailed  at  great  length  by  Meckel,^  seems  also  in  its  principal 
points  justly  referable  to  the  present  division  of  cases,  although 
there  was  at  the  same  time  a tendency,  in  the  unequal  size  of  the 
two  cornua  uteri,  etc.,  to  a degree  of  lateral  hermaphroditism. 

Professor  Mayer  of  Bonn  has  detailed  at  length  the  dissection 
of  three  hermapliroditic  goats,  in  all  of  which  the  conformation 
of  the  sexual  parts  resembled  in  its  more  essential  features  the 
preceding  cases  of  Thomas  and  Gurlt.  In  all  the  three  instances 
there  were  found  two  male  testicles  with  their  epididymes,  vasa 

^ Lehrhuch  dcr  Pathol.  Anat.,  bd.  ii.  s.  195,  pi,  ix,  figs.  1 and  2,  and  pi.  xxii, 
figs.  3 and  4. 

2 Atti  del  Peal  Instil.  d'Ineoragg.  alle  Sc.  Nat.,  Naples,  tom.  iii.  p.  380. 

^ Eeil’s  Archiv  fiir  die  Physiologic,  bd.  xi.  s.  334-38. 

^ leones  Select.  Praeparat.  Mii-s.  Anat.,  Bonn,  pp.  17-20,  tab.  iv.  fig.  5,  and 
tab.  V.  figs.  1,  2,  and  3. 


462 


HERMAPHRODITISM. 


deferentia,  and  vesiculse  seminales ; and  at  the  same  time  there  was 
present  a well-marked  two-horned  uterus,  with  a vagina  opening 
into  the  urethra.  In  the  first  case  the  large  hollow  coruna  uteri 


terminated  in  blind  extremities,  and  there  were  only  very  short 
impervious  rudiments  of  the  Fallopian  tubes.  In  the  second  case,  at 
the  extremity  of  the  right  horn  of  the  uterus,  a blind  appendiculum 
was  situated,  formed  by  a vestige  (according  to  ]\Iayer)  of  the 

Fig.  14.  rt  a,  The  testicles  ; 6 I,  epidiilymes  ; c c,  rasa  deferentia  ; d d,  vesi- 
culai  seminales. 


DOUBLE  HERMA.PHRODITISM. 


4G3 


Fallopiaji  tube  ; and  from  this  a ligament  was  sent  off  to  the  cor- 
responding testicle ; a similar  ligament,  but  no  appendicula,  existed 
on  the  left  side.  In  the  third  case  both  Fallopian  tubes  were 
present,  and  each  ended  in  a bursa  formed  by  the  lamina  of  the 
peritoneum,  and  partly  surrounding  the  testicle  and  epididymes. 
In  two  of  the  instances  the  ejaculatory  ducts  seem  to  have  opened 
into  the  urethra  near  the  point  at  which  the  vagina  terminated  in 
it ; and  in  one  of  the  cases  they  opened  into  the  canal  of  the  vagina 
itself  before  it  joined  that  of  the  urethra.  All  the  external  organs 
were  male,  but  malformed  in  so  far  that  the  penis  was  short,  and  in 
two  of  the  cases  somewhat  twisted ; and  the  scrotum  was  either 
small  or  wanting.^ 

The  same  author*  has  described  the  dissection  of  a dog,  the 
sexual  organs  of  which  exhibited  a similar  variety  of  hermaphro- 
ditic malformation.  The  Fallopian  tubes  were  pervious  throughout 
in  this  instance,  and  at  their  further  extremities  opened  upon  the 
neighbouring  cellular  tissue.  The  body  of  the  two-horned  uterus 
was  very  small.  On  compressing  the  epididymes  and  vasa  defe- 
rentia,  a fluid  resembling  semen  issued  from  the  openings  of  the 
latter  into  the  urethra.  The  external  sexual  parts  were  those  of  a 
hypospadiac  male. 

Several  cases  of  hermaphroditic  malformation  in  the  human 
subject,  similar  in  their  anatomical  characters  to  the  preceding,  have 
been  described  by  Columbus,  Harvey,  Petit,  Ackermann,  Steghlener, 
and  Mayer. 

a.  In  a person  with  external  hypospadiac  male  organs,  Colum- 
bus^ found  two  bodies  like  testicles  in  the  situation  of  the  ovaries, 
and  larger  in  size  than  the  latter  female  organs  naturally  are.  From 
each  of  these  testiform  bodies  two  sets  of  tubes  arose,  one  of  which, 
like  the  male  vasa  deferentia,  passed  on  to  the  root  of  the  penis 
and  opened  into  the  urethra ; while  the  other,  like  the  female  Fal- 
lopian tubes,  were  inserted  into  a uterus.  The  prostate  gland  was 
absent. 

b.  Harvey^  has  mentioned  a very  small  hermaphroditic  embryo, 
on  which  he  found  a two-horned  uterus  with  two  testicles  of  a very 
small  size,  and,  near  the  diminutive  penis,  some  traces  of  a prostate 
gland. 

^ For  other  similar  cases  in  the  goat,  see  Lenckart,  in  CijcloiKcdia  of  Anatomy, 
vol.  iv.,  p.  1426  ; and  Kobelt’s  Ncbow-Elcr stock  dcs  JVcibes,  etc.,  p.  38. 

2 Loc.  cit.  p.  16,  tab.  iv.  lig.  3,  external  parts  of  generation  ; fig.  4,  internal. 

^ Dc  lie  Anat.  lib.  xv.  * De  Gen.  Anim.  Exerc.  Ixix,  p.  304. 


464 


HERMAPHRODITISM. 


c.  The  observation  of  M.  Petit*  of  Namur  is  still  more  complete. 
On  the  body  of  a soldier,  aged  twenty-two,  who  died  of  his  wounds, 
and  whose  external  organs  appear  to  have  presented  no  deviation 
from  the  male  type  except  in  the  absence  of  the  testicles  from  the 
scrotum,  these  bodies,  with  male  vasa  deferentia,  vesiculse  serninales, 
and  a prostate,  were  found  to  co-exist  with  female  Fallopian  tubes, 
and  a uterus  that  was  attached  to  the  neck  of  the  urinary  bladder, 
and  opened  into  the  urethra  between  this  neck  and  the  prostate. 
The  form  of  this  imperfect  uterus,  M.  Petit  remarks,  merited  for  it 
rather  the  name  of  a vagina  than  of  a uterus,  and  it  resembled 
more  this  organ  in  the  female  quadruped  than  in  women.  From  the 
body  of  the  uterus,  at  three  inches  from  its  entrance  into  the  urethra, 
two  Fallopian  tubes  arose.  These  tubes  were  perforated,  and  were 
three  inches  and  a half  long ; their  abdominal  extremities  were  not 
loose  and  provided  with  fimbrise,  but  were  attached  to  a small  soft 
body  on  each  side,  occupying  nearly  the  natural  situation  of  the 
ovaries,  but  having  the  substance  or  structure  of  the  testicles,  and 
provided  with  an  epididjanis  and  vas  deferens.  The  vasa  deferentia 
were  each  seven  inches  and  a half  long,  and  were  attached  to  two 
long  and  rather  slender  vesicula3  serninales  placed  alongside  of  the 
uterus.  The  vesiculse  opened  into  the  urethra  by  two  ducts. 

In  a note  appendid  to  this  case,  M.  Petit  states  that  he  had 
been  consulted  by  a man  who  passed  blood  by  the  penis  regularly 
every  month,  without  pain  or  any  troublesome  symptom.  Perhai)s, 
adds  M.  Petit,  this  man  had  also  a concealed  uterus.  I have  been 
informed,  on  credible  authority,  of  two  similar  cases,  the  one  in  a 
young  unmarried  man  of  seventeen  years  of  age,  and  the  other  in  a 
person  who  had  been  married  for  several  years  without  his  wife 
having  had  any  children.  In  both  of  these  cases  the  discharge 
was  in  very  considerable  quantity,  and  perfectly  regular  in  its 
monthly  occurrence.  Did  it  consist  in  a periodical  hemorrhage 
from  the  urinary  bladder  or  passages  only  1 Or  was  it,  as  M.  Petit 
seems  to  suppose  in  his  instance,  of  a true  menstrual  character,  and 
produced  by  a female  uterus,  etc.,  existing  internally,  and  comniuni- 
catiiig  as  usual  with  the  canal  of  the  urethra?' 

^ Hist,  dc  V Acad.  I^oy.  dcs  Sc.  for  1720,  p.  38. 

2 ilore  lately,  several  similar  cases  have  been  recorded  of  apparent  menstruation 
througn  a perforate  penis,  as  by  Harris,  in  American  Journal  of  the  Medical 
Sciences  for  July  1847  ; two  cases  by  Blackman,  in  Ibid,  for  July  1843,  etc.  In 
an  American  case,  that  of  Suydam,  there  was  one  descended  testis,  and  a hypo- 
spadiac  penis.  This  person  is  said  to  have  had  a regular  catamenial  discharge. 
The  question  was  raised  as  to  whether  this  person  was  a male  or  female,  and 


DOUBLE  HERMAPHRODITISM. 


465 


d.  Professor  Ackermann’  of  Jena  publislied  in  1805  the  follow- 
ing interesting  case  of  the  present  variety  of  hermaphroditic  mal- 
formation. It  occurred  in  an  infant  that  lived  about  six  weeks  after 
birth.  On  dissection,  two  testicles  were  found  ; one  of  them  had 
descended  into  the  scrotum  or  labium ; the  other  had  advanced  no 
further  than  the  groin.  Both  were  perfectly  formed,  and  had  their 
usual  appendages  complete.  In  the  natural  situation  of  the  female 
uterus,  there  was  found  a hollow  pyriform  organ,  which,  from  its 
locality  and  connections,  was  supposed  to  be  a uterus,  though  its 
coats  were  finer  and  thinner,  and  its  cavity  greater,  than  naturally 
belongs  to  that  viscus.  Duplicatures  of  peritoneum,  resembling  the 
ligamenta  lata,  connected  this  imperfect  uterus  with  the  sides  of 
the  pelvis,  and  its  cavity  opened  into  a kind  of  short  vagina,  which 
soon  united  with  the  urethra,  and  formed  one  common  canal  with 
it,  vagina  urethralis.  The  vasa  deferentia  ran  from  the  testicles  to- 
wards the  superior  angles  of  the  uterus,  and  penetrated  into  its  sub- 
stance at  the  points  where  the  Fallopian  tubes  are  usually  placed. 
Without  opening  here,  however,  they  passed  onwards  under  the 
internal  mucous-like  membrane  of  the  uterus  and  vagina,  and  at 
length  terminated,  by  very  small  orifices,  in  the  vagina  urethralis. 
Immediately  previous  to  entering  the  ligamenta  lata,  each  vas  defe- 
rens formed  a number  of  convolutions,  conglomerated  into  a mass 
resembling  a vesicula  seminalis. 

e.  Steghlener^  has  described  at  great  length  the  case  of  an  infant 
that  survived  only  for  half-an-hour  after  birth,  upon  whose  body  he 
found  perfect  external  male  organs  (Fig.  15,  a h),  and  internally  two 
small  elongated  testicles,  c c,  with  their  epididymes,  g g,  and  the  con- 
volutions of  imperforate  vasa  deferentia,  h h,  distinctly  marked.  The 
testes  were,  as  seen  in  the  sketch,  supplied  with  spermatic  arteries  fol- 
lowing their  usual  course.  Between  the  rectum  and  bladder  there  was 
placed  a very  large  pear-shaped  bag  or  pouch,  /,  with  firm,  coriaceous, 
but  not  thick,  walls,  and  distended  with  fluid.  This  bag  or  imperfect 
cystoid  uterus  terminated  interiorly  by  a narrow  neck  in  a vagina 
that  opened  into  the  urethra  in  the  situation  of  the  verumontanum, 
and  was  there  dilated  into  a large  bag  or  ampulla,  occupying  exactly 
the  site  of  the  prostate  gland,  and  resembling  this  organ  also  in  its 
form  and  position.  The  internal  membrane  of  the  uterus  was  col- 

entitled  or  not  entitled  to  vote  as  a freeman  at  a political  election.  See  Dr.  Tay- 
lor’s Medical  JurisiJrudence,  p.  613.  See  also  Ibid.,  p.  256. 

^ “ Infantis  androgyni  liistoria  et  iconographia  ; ” Edin.  Med.  and  Surg.  Jour- 
nal, vol.  iii.  p.  202.  - Dc  llcrvuqdir.  Ned.  p.  104. 


466 


HERMAPHRODITISM. 


lected  at  its  neck  into  numerous  valvular-like  folds,  and  that  of  the 
vagina  had  also  a rugous  or  plicated  arrangement.  From  the 

fundus  of  the  large  sac  of  the 
uterus,  and  not  from  its  angles, 
hut  from  near  its  middle,  two 
impervious  solid  ducts  (vasa 
deferentia)  arose,  and  after  a 
somewhat  tlexuous  course 
reached  the  testicle,  c c,  ly- 
ing in  the  superior  part  of 
the  iliac  fossae.  These  ducts 
had  attached  to  them  at  one 
or  two  points  a number  of 
small  reddish  nodules,  h h, 
consisting,  according  to  Stegh- 
lener, 

and  described  by  Ackermann, 
in  his  case,  as  vesiculae  semi- 
nales.  The  canal  of  the  ure- 
thra was  obliterated  for  a 
short  distance  towards  the 
fossa  navicularis,  and  the  uri- 
nary bladder,/,  and  uterus,  i i, 
were  extremely  distended,  and 
the  left  kidney,  m,  was  vesi- 
cular. 

Mayer,  in  the  work  al- 
ready referred  to,^  has  described  and  delineated  the  following  five 
cases  of  the  present  species  of  hermaphroditic  malformation  in  the 
human  subject,  all  of  which  he  had  himself  met  with  and  dissected. 

/.  In  a foetus  of  the  fourth  month,  and  affected  with  omphalo- 
cele and  extroversion  of  tlie  urinary  bladder,  he  found  male  testicles 
(Fig.  16,  a a)  with  their  epididymes,  b h,  and  a two-horned  uterus,  c, 
terminating  in  a vagina,  d,  that  opened  into  the  posterior  part  of 
the  urinary  bladder,  e.  From  the  left  testicle  a contorted  vas 
deferens,  /,  arose,  and  ran  down  to  the  vagina ; the  right  vas 
deferens,  g,  was  shorter,  and  became  threadlike,  and  disappeared 
near  the  corresponding  cornu  of  the  uterus.  A rudiment  only  of 
the  left  male  vesicula  seminalis  was  observable.  The  external 
organs  were  male ; the  glans  penis,  /?,  was  imperforate. 

^ Iconcs  Select,  etc.,  pp.  8-16.  See  also  Waltlier  and  Graefe’s  Journal  der 
Chiriirgic  und  Aur/enhcilkunde,  bd.  vii.  lift.  3 ; and  bd.  viii.  lift.  2. 


of  glandular  granules. 


MAYEP/S  CASES  IN  MAN. 


407 


g.  In  another  foetus  of  the  sixth  month/  there  existed  a perfect 
set  of  internal  and  external  male  sexual  organs — viz.  testicles,  epidi- 
dymes,  vasa  deferentia,  and  vesicula  serninales — with  a prostate 
gland  and  a normally-formed  penis  and  scrotum.  But,  besides 


these,  there  was  also  present  an  imperfect  female  uterus,  the  body 
of  which  divided  into  two  cornua,  the  right  longer  and  incurvated, 
the  left  shorter  and  sacciform.  The  neck  of  the  uterus  was  marked 
internally  by  its  usual  arborescent  appearance  ; and  it  opened  into  a 
vagina  that  terminated  in  the  urethra  near  the  exit  of  the  latter 
from  the  urinary  bladder. 

h.  In  a third  case*  of  hermaphroditic  malformation  in  an  infant 
who  died  of  convulsions  when  six  months  old,  iVIayer  found  the 
following  blending  of  the  organs  of  the  two  sexes.  Of  the  internal 
male  genital  organs  there  were  present  two  bodies  at  the  inguinal 
rings,  that  were  evidently  testicles  (Fig.  17,  a a),  as  was  proved  not 
only  by  their  position,  but  by  their  form,  coverings,  connections, 
and  internal  structure,  “ tlieir  substance,”  says  Mayer,  “ being 
evidently  composed  of  yellow  canals;”  their  epididymes,  hb,  were 
also  distinctly  developed,  and  each  of  them  sent  off  a vas  deferens, 
c c,  which  was  furnished  with  a corresponding  multilocular  vesicula 
seminalis,  d d.  Of  the  internal  female  sexual  organs  there  were 
found  a perfectly  developed  uterus,  e e,  with  its  broad,  n n,  and 
round,  o o,  ligaments  naturally  formed  and  placed,  and  provided 
with  two  Fallopian  tubes,//,  that  followed  the  course  of  the  tes- 
ticles through  the  inguinal  canals,  and  a vagina,  g,  which  opened 
into  the  urethra.  A,  near  its  external  orifice.  The  ejaculatory  ducts 

Tcones,  p.  8,  tab.  ii.  fig.  5.  ^ Ibid.,  p.  9,  tab.  iii.  figs.  1 and  2. 


1 


4G8 


HERMAPHRODITISM. 


of  tlie  male  vesiculse  seminales  opened  into  this  vagina  at  I and  m. 
The  internal  surface  of  the  vagina  was  already  beginning  to  present 
the  appearance  of  its  usual  rugae.  The  cavity  of  the  uterus  was 
triangular,  and  exhibited  on  the  internal  part  of  the  cervix  its 


characteristic  plicated  or  arborescent  structure.  The  Fallopian 
tubes  were,  at  their  uterine  orifices,  of  a large  calibre ; their  cavity 
afterwards  became  suddenly  contracted,  and  then  again  dilated,  and 
terminated  at  their  ulterior  extremities,  where  they  lay  in  contact 
Avith  the  testicles  at  the  external  inguinal  rings,  in  blind  sacs,  i i, 
without  any  very  distinct  appearance  of  fimbriae.  The  external 
genital  parts  in  this  very  interesting  case  Avere  of  a doubtful  nature, 
being  referable  either  to  those  of  a hypospadiac  male,  or  of  a female 
Avith  a large  clitoris,  but  Avithout  nymphae,  the  meatus  urinarius 
being  in  its  normal  situation,  but  leading  behind  to  the  cavities^  of 
both  the  urinary  bladder  and  uterus.  The  circle  of  the  pelvic  bones 
was  large. 

i.  The  tAvo  other  instances  described  by  Mayer  occurred  in  adult 


MAYER’S  CASES  IN  MAN. 


469 


subjects,  and  the  malformation  in  both  of  them  differed  from  that 
found  in  the  cases  just  now  cited,  in  this,  that  there  was  only  one 
testicle  present  along  with  the  imperfect  uterus. 

The  subject  of  one  of  these  cases'  was  a person  who  died  at  the 
age  of  eighteen,  and  whose  external  sexual  organs  were  those  of  a 
hypospadiac  male,  with  a narrow  perineal  canal  or  fissure.  On  dis- 
section, this  perineal  canal  was  found  to  communicate  anteriorly 
with  the  urethra,  and  posteriorly  with  a vagina  of  two  inches  and 
nine  lines  in  length,  and  five  or  six  lines  in  calibre.  The  anterior 
and  posterior  columns  of  rugse  belonging  to  the  vagina  were  only 
slightly  marked.  Its  canal  led  to  a large  dilated  uterus,  the  superior 
part  of  which  was  unfortunately  cut  away  with  some  diseased  vis- 
cera before  the  genital  organs  were  examined ; but,  from  the  por- 
tion left,  this  organ  seemed  to  resemble  the  uterus  of  quadrupeds  in 
its  oblong  form,  and  in  the  thinness  of  its  walls,  which  were  com- 
posed of  a cavernous  fibro-vascular  texture,  and  full  of  lacunae.  The 
usual  arborescent  appearance  of  the  internal  surface  of  the  os  uteri 
was  very  perfectly  marked.  Beside  these  female  organs,  there  was  a 
well-formed  male  prostate  gland  at  the  neck  of  the  bladder ; and 
behind  the  abdominal  ring  of  the  right  side,  a small  roundish  body, 
similar  in  form  and  texture  to  the  testicle,  and  having  the  cremaster 
muscle  adhering  to  its  membranous  involucrum.  Tliere  were  no 
traces  of  any  similar  organ  on  the  left  side.  On  both  sides  some 
portions  of  a canal  were  seen,  but  whether  they  were  the  remains  of 
the  vasa  deferentia  or  Fallopian  tubes  was  not  ascertained,  on  account 
of  the  previous  mutilation  of  the  uterus.  On  each  side  of  the  neck 
of  the  uterus  there  was  placed  a vesicula  seminalis,  provided  with  an 
ejaculatory  duct  that  opened  into  the  orifice  of  the  vagina.  The 
dimensions  of  the  pelvis  approached  much  nearer  to  those  of  the 
female  than  those  of  the  male.  In  the  secondary  sexual  characters 
of  the  individual,  the  female  type  was  further  recognised  in  the  want 
of  prominence  in  the  larynx,  in  the  slender  form  of  the  neck,  and 
(according  to  Professor  Mayer)  in  the  rounded  shape  also  of  the 
heart,  the  smallness  of  the  lungs,  the  oblong  shape  of  the  stomach, 
the  large  size  of  the  liver,  the  narrowness  of  the  forehead,  and  the 
conformation  of  the  brain ; while  the  individual  approximated,  on 
the  other  hand,  to  the  male  in  the  length  and  position  of  the  in- 
ferior extremities,  in  the  breadth  of  the  thorax,  the  undeveloped 
state  of  the  mamma3  and  the  hairy  condition  of  their  papillse,  and 
in  the  existence  of  a slender  beard  upon  the  chin  and  cheeks. 

^ leones,  p.  11,  tab.  iii.  figs.  3 and  4. 


470 


IIERMAPIIllODITISM. 


j.  In  the  second  adult  subject,  a person  eighty  years  of  age, 
Mayer  found,*  on  the  left  side  of  the  cavity  of  the  abdomen,  and 
near  the  inguinal  ring,  a small  oval  body  exhibiting  imperfectly  in 
its  internal  structure  the  tul^ular  texture  of  the  male  testicle,  and 
having  an  appendix  resembling  the  epididymis  attached  to  it. 
From  this  testicle  arose  a vas  deferens,  which  was  joined  in  its 
course  by  a vesicula  seminalis,  and  ended  in  an  ejaculatory  duct. 
On  the  opposite  or  right  side,  a vesicula  seminalis,  having  no  con- 
tinuous cavity,  was  present ; but  no  vestige  of  a corresponding 
testicle,  vas  deferens,  or  ejaculatory  duct,  could  be  discovered.  The 
prostate  gland  was  present,  and  regularly  formed.  In  the  cavity  of 
the  pelvis  a uterus  was  found  with  parietes  of  moderate  thickness, 
and  of  the  usual  cavernous  texture ; its  cervix  was  marked  inter- 
nally with  the  appearance  of  the  natural  arborescent  rugoe.  Inte- 
riorly it  opened  into  a narrow  membranous  vagina,  that  received  the 
right  ejaculatory  duct,  then  passed  through  the  body  of  the  prostate, 
and  latterly  joined  the  canal  of  tlie  urethra.  The  fundus  of  the 
uterus  could  not  be  examined,  as  it  had  been  removed  in  a previous 
stage  of  the  dissection.  The  external  parts  were  male  and  naturally 
formed,  with  the  exception  of  the  penis,  which  was  shorter  than 
usual,  and  had  the  canal  of  the  urethra  fissured  interiorly,  and  the 
meatus  urinarius  situated  at  its  root.  The  individual  was  during 
life  regarded  as  a male,  but  had  all  along  remained  in  a state  of 
celibacy.  The  general  appearance  of  the  face  and  body  was  that  of 
an  imperfectly  marked  male,  but  the  pelvis  was  broad  like  that  of  a 
female.* 

3.  CO-EXISTENCE  OF  FEMALE  OVARIES  AND  MALE  TESTICLES. 

This  third  division  of  complex  or  double  hermaphroditism  in- 
cludes all  those  cases  in  which  a male  testicle  and  female  ovary 
exist  together,  either  upon  one  side  only,  or  upon  both  sides  of  the 
body.  With  this  arrangement,  other  malformations  by  duplicity  of 
the  sexual  organs  are  generally  combined  ; but  these  are  so  various 
in  their  character  as  not  easily  to  admit  of  any  useful  generalisation. 
In  considering  this  third  division  of  complex  hermaphroditism,  we 

^ Iconcs,  p.  15,  tab.  iv.  figs.  1 and  2. 

2 For  an  account  in  tlie  human  subject  of  two  additional  cases  of  this  variety 
of  hermaphroditic  malformation — viz.,  an  imperfect  male  organisation,  with  the 
addition  of  a highly  developed  uterus — see  AVeber’s  Zusdtze  zur  Ichre  clcr  Gesch- 
Icchtsorganc,  p.  15  ; or  Maret,  in  the  Memoires  clc  V Acad,  de  Dijon,  1772,  p.  157  ; 
and  Chevreul  in  Journal  de,  Medccinc  for  1779,  p.  441. 


DOUBLE  HERMAPHRODITISM. 


471 


shall  mention,  first,  the  cases  in  which  two  testicles  and  one  ovary  are 
stated  to  have  co-existed ; and  secondly,  those  in  which  there  have 
• been  supposed  to  be  present  two  testicles  and  two  ovaries. 

Two  testicles  and  one  ovary. — The  two  dissections  that  we  have 
previously  detailed  of  lateral  hermaphroditic  insects,^  show  that  in 
these  two  cases  this  variety  of  sexual  duplicity  existed.  It  appears 
to  have  been  observed  also  in  two  instances  of  hermaphroditic  mal- 
formation in  the  quadruped,  the  histories  of  which  have  been  de- 
scribed by  Mascagni  and  Mayer. 

In  a bull,  nine  years  of  age,  and  which  was  provided  Avith  the 
usual  external  organs  of  the  male,  Mascagni  found  internally,  on  dis- 
section, a prostate  gland  and  two  perfect  vesicula)  seminales,  vasa 
deferentia,  epididymes,  and  testicles.  The  testicles  and  epididymes 
Avere  injected  Avith  mercury  through  the  vasa  deferentia.  Tii  addi- 
tion, there  Avas  discovered  near  the  left  testicle,  and  connected  to  it 
by  peritoneum  and  blood-vessels,  a body  having  the  structure  of  the 
female  ovary  ; and,  in  its  normal  situation,  there  existed  a distended 
double  uterus,  containing  from  fifteen  to  sixteen  pounds  of  a clear 
fluid.  This  uterus  was  furnished  Avith  tAvo  Fallopian  tubes  at  its 
upper  part,  and  terminated  interiorly  in  a vagina,  A\diich  opened  by 
a small  orifice  into  the  male  urethra.^ 

In  a'  goat,  dissected  by  Mayer,^  he  found  tAvo  testes  Avith  their 
epididymes  fully  developed,  and  vasa  deferentia  and  vesiculse  semi- 
nales. One  of  the  testes  Avas  placed  without,  and  the  other  still 
remained  Avithin  the  abdominal  cavity.  At  the  same  time  there 
were  present  a large  female  vagina  communicating  Avith  the  urethra, 
and  a double-horned  uterus  provided  Avith  tAvo  Fallopian  tubes.  One 
of  these  tubes  terminated  in  a blind  canal,  but  the  other  had  placed 
at  its  abdominal  extremity  seA^eral  Amsicles,  resembling,  according  to 
Mayer,  Graafian  vesicles,  or  an  imperfect  ovary.  The  vesiculoe 
seminales,  and,  through  regurgitation  by  the  urethra  and  ejaculatory 
ducts,  the  cavities  of  the  vagina  and  uterus,  Avere  filled  Avith  about 
four  ounces  of  a Avhitish  fluid,  having  the  colour  and  odour  of  male 
semen.  This  fluid  could  not  be  found  by  the  microscope  to  contain 
any  seminal  animalcules,  but  only  simple  and  double  Monades 
(Monades  termones  et  guttulas).  Bergmann,  hoAvever,  is  alleged  to 
have  found  it,  on  analysis,  to  contain  the  same  chemical  principle 
that  characterises  human  male  semen. 

Two  testicles  and  tivo  ovaries. — Various  instances  have  now  beem 

^ See  p.  434,  under  Lateral  Hermaphroditism. 

* Atti  delVAcad.  delU  Scienze  di  Siena,  tom.  viii,  p.  201. 

86 


“ Iconcs,  p.  20i 


472 


HERMAPHRODITISM. 


published  in  which  this  sexual  duplicity  has  been  supposed  to  exist 
among  cattle  and  other  domestic  quadrupeds,  as  well  as  in  the 
human  subject. 

One  of  the  free-martins,^  described  by  Mr.  Hunter,  comes  under 
this  variety.  In  the  case  referred  to,  in  the  situation  of  the  ovaries 
“ were  placed,”  to  use  Mr.  Hunter’s  words,  “ both  the  ovaria  and 
testicles,” — or,  as  Sir  Everard  Home,  in  alluding  to  this  case,  more 
justly  expresses  it,  “ an  appearance  like  both  testicles  and  ovaria  was 
met  with  close  together.”^  The  two  contiguous  bodies  were  nearly 
of  the  same  size,  being  each  about  as  large  as  a small  nutmeg.  There 
were  no  Fallopian  tubes  running  to  the  ovaries,  but  a horn  of  an 
imperfect  uterus  passed  on  to  them  on  each  side  along  the  broad 
ligament.  Pervious  vasa  deferentia  were  found  ; they  did  not,  how- 
ever, reach  up  completely  to  the  testicle  on  either  side,  or  form 
epididymes.  The  vesiculae  seminales  were  present,  and  much  smaller 
than  in  the  perfect  bull.  The  external  parts  appear  to  have  been 
those  of  the  cow,  but  smaller  than  natural.  The  vagina  passed  on, 
as  in  the  cow,  to  the  opening  of  the  urethra,  and,  after  having  re- 
ceived it  and  the  orifices  of  the  seminal  ducts,  it  began  to  contract 
into  a small  canal,  which  ran  upwards  through  the  uterus  to  the  place 
of  division  of  that  organ  into  its  two  horns.  . 

Velpeau,^  in  his  work  on  Midwifery,  mentions  that  in  an  embryo 
calf,  he  had  “found  reunited  the  testicles  and  ovaries,  the  vasa 
deferentia  and  uterus.” 

In  a hermaphroditic  foal-ass,  Mr.  Hunter^  found  both  what  he 
considered  to  be  two  ovaries  placed  in  the  natural  situation  of  these 
bodies,  and  two  testicles  lying  in  the  inguinal  rings  in  a process  or 
theca  of  peritoneum  similar  to  the  tunica  vaginalis  communis  in  the 
male  ass.  No  vasa  deferentia  or  Fallopian  tubes  could  be  detected ; 
but  there  was  a double-horned  uterus  present,  and  from  its  broad 
ligaments,  to  the  edges  of  which  the  cornua  uteri  and  ovaries  were 
attached,  there  passed  down  on  either  side  into  the  inguinal  rings  a 
])art  similar  to  the  round  ligament  in  the  female.  The  horns  and 
fundus  of  the  uterus  were  pervious ; but  its  body  and  cervix,  and 
the  canal  of  the  vagina  from  above  the  opening  of  the  urethra  into 
it,  were  imperforate.  The  external  parts  were  similar  to  those 
of  the  female  ass ; but  the  clitoris,  which  was  placed  within  the 
.entrance  of  the  vagina,  was  much  larger  than  that  of  a perfectly 

^ An.  Econ.  pp.  63-64,  pi.  ix.  ^ Comp.  Anat.  vol.  iii.  p.  322. 

^ Traite  de  V Art  dcs  Accoucliemens,  tom.  i.  p.  114.  An.  Econ.  p.  58. 


DOUBLE  HERMAPHRODITISM. 


473 


formed  female ; it  measured  about  five  inches.  The  animal  had 
two  nipples. 

Scriba  has  given  an  account^  of  a hermaphroditic  sheep,  in 
which  two  large  testicles  are  stated  to  have  been  found  in  the 
scrotum,  at  the  same  time  that  there  existed,  in  their  normal  situa- 
tion, two  moderately-sized  ovaries,  and  a small  uterus  furnished 
with  two  apparently  closed  Fallopian  tubes.  The  external  sexual 
parts  appear  to  have  been  those  of  a malformed  male,  the  penis  being 
short  and  impervious,  the  scrotum  divided,  and  the  urethra  opening 
into  a contracted  perineal  fissure  resembling  the  female  vulva.  This 
animal  had  often  attempted  connection  with  the  female  sheep. 

Borkhausen*^  has  described  a very  similar  case  in  the  same  species 
of  animal.  Each  half  of  the  divided  scrotum  contained  a testicle, 
which  was  regularly  formed,  but  greater  in  size  than  usual,  and  fur- 
nished with  a large  spermatic  artery.  The  pelvis  contained  a normal 
uterus,  which  was  smaller,  however,  than  natural ; it  was  provided 
with  its  usual  ligaments.  The  Fallopian  tubes  were  present,  but 
imperforate,  and  the  two  ovaries  were  full  of  vesicles,  and  inclosed  in 
a strong  membrane.  The  vagina  was  natural,  and  opened  as  in  the 
female.  Behind  the  divided  scrotum,  the  rudiment  of  an  udder  with 
four  teats,  instead  of  two,  was  situated.  The  male  penis  was  also 
present,  but  diminutive  and  short ; its  erector  muscles  were  small, 
and  the  prostate  gland  indistinct.  The  urethra  was  single  as  it  left 
the  bladder,  but  it  afterwards  divided  into  two  canals,  the  wider  of 
which  opened  into  the  female  vagina  and  vulva,  and  the  narrower 
ran  through  the  male  penis.  The  urine  passed  in  a full  stream 
through  the  former  canal,  and  only  by  drops  through  the  latter. 
The  animal  is  alleged  to  have  attempted  coition  in  both  ways. 

In  1829,  an  account  of  a hermaphroditic  goat  was  published 
at  Naples,  which  is  said  to  have  been  provided  with  both  female 
ovaries  and  male  testicles.’  The  two  ovaries  occupied  their  usual 
situation ; no  Fallopian  tubes  were  found ; but  there  were  present 
a double-horned  uterus  with  blind  cornua,  and  a vagina  which 
opened  externally,  as  in  the  female.  In  the  neighbourhood  of  the 
ovaries,  and  more  external  than  them,  two  small  testicles  were  dis- 
covered, having  two  vasa  deferentia  arising  from  them.  The  vasa 
deferentia  ran  downwards  to  two  corresponding  vesiculae  seminales, 

^ SchH f ten  dcr  Gcscllschaft  Naturforschender  Frcimdc  zu.  Berlin,  Bd.  x.  s.  367. 

- Bheinisches  Mctg.  zur  Erweiteriing  der  Naturkundc,  Giessen,  1793,  Bd.  i.  s.  608. 

^ Brevi  cenni  sic  di  un  Ncutro  Capro;  or,  Guilt’s  Pathologischen  Anatomie, 
Bd.  ii.  s.  198. 


474 


HERMAPHRODITISM. 


that  were  placed  alongside  of  the  uterus.  In  the  lower  angle  of  the 
external  pudenda,  a body,  resembling  in  length  the  male  penis  more 
than  the  female  clitoris,  was  situated  : it  was,  as  we  have  already 
had  frequently  occasion  to  mention  in  regard  to  the  penis  in  mal- 
formed male  quadrupeds,  of  a very  tortuous  or  convoluted  form. 

I have  had  an  opportunity  of  examining  an  excellent  preserved 
specimen  of  double  hermaphroditism  in  the  sow,  referable  to  the 
present  section,  which  was  met  with  some  years  ago  by  Dr.  Knox, 
and  I have  his  permission  to  state  here  the  following  particulars  of 
the  case. 

Among  the  internal  female  organs  there  is  present  a natural 
well-formed  double  uterus,  provided  with  broad  ligaments  and  two 
hollow  cornua,  each  about  six  or  seven  inches  in  length.  The  fim- 
briated extremities  are  not  distinctly  marked,  the  female  tubes 
appearing  to  end  blind  at  their  upper  terminations,  as  they  have 
often  been  observed  to  do  in  similar  cases.  The  os  uteri  opens 
inferiorly  into  a vagina,  which  seems  normal  in  its  structure.  At  a 
short  distance  from  the  upper  extremity  of  each  horn  of  the  uterus, 
two  bodies  of  considerable  magnitude  are  seen  lying  in  close  juxta- 
position. The  smaller  of  these  two  bodies  is  on  either  side  about 
the  size  and  shape  of  a large  almond  ; and  though  internally  of  an 
indeterminate  amorphous  structure,  they  are  considered  by  Dr. 
Knox  as  answering  to  the  two  ovaries.  The  two  larger  bodies, 
which  are  placed  between  the  supposed  ovaries  and  the  upper  extre- 
mities of  the  cornua  uteri,  are  most  distinctly  testicles,  as  shown  by 
their  numerous  tortuous  seminiferous  tubes,  which  have  been  success- 
fully filled  with  a mercurial  injection.  They  are  of  the  full  size  of 
the  organ  in  the  adult  male.  The  seminiferous  tubes  of  each  testicle 
terminate  in  a vas  deferens,  which  was  injected  from  them  ; and  the 
two  vasa  deferentia  run  downwards  through  the  ligarnenta  lata  of 
the  uterus,  and  terminate  inferiorly  in  the  upper  part  of  the  vagina, 
thus  following  the  course  of  those  natural  canals  in  the  female  sow 
that  we  shall  afterwards  have  occasion  to  allude  to  at  greater  length 
under  the  name  of  Gaertner’s  ducts,  and  which  Dr.  Knox,  from  the 
evidence  of  the  present  case,  believes  to  be  in  reality  typical  of  the 
male  vasa  deferentia.  There  is  no  trace  of  vesiculoe  seminales. 
Externally,  the  vagina  opened  along  with  the  urethra  upon  the 
perineum,  at  a point  lower  than  natural  in  the  well-formed  female. 
The  clitoris,  in  situation  and  size,  was  nearly  normal. 

The  animal,  at  the  time  of  death,  was  fourteen  months  old ; it 
was  ferocious  in  its  habits ; and  it  had  been  in  vain  tried  to  be 


DOUBLE  HERMAPHRODITISM. 


475 


fattened.  It  had  repeatedly  shown  strong  male  propensities,  and  at 
the  season  of  heat  its  vagina  is  said  to  have  presented  the  usual 
injected  appearance  observed  in  the  female  sow. 

Dr.  Harlan  of  Philadelphia^  has  lately  described  a still  more 
perfect  case  of  double  hermaphroditism  than  any  of  the  preceding, 
which  he  met  with  in  the  body  of  a gibbon  or  orang-outang  {Simla 
concolor)  from  the  Island  of  Borneo.  This  animal  died  of  tubercular 
disease  in  Philadelphia  in  1826,  when  it  was  considered  to  be  under 
two  years  of  age.  Dr.  Harlan  gives  the  following  account  of  its 


Fig.  18.  Fig.  19. 


sexual  formation.  The  penis  (Fig.  18,  a)  was  about  one  inch  in 
length,  and  subject  to  erections ; it  terminated  in  an  imperforate 
glans ; and  a deep  groove  on  its  inferior  surface  served  as  a rudi- 
mentary urethra.  This  groove  extended  about  two-thirds  of  the 
length  of  the  penis,  the  remaining  proportion  being  covered  with  a 
thin  reticular  diaphanous  membrane,  which  extended  also  across  the 
vulva,  h,  and  closed  the  external  orifice  of  the  vagina.  The  vagina 

Fig.  18.  External  sexual  organs  and  testicles  ; g g,  the  prepuce  ; lih,  the  vasa 
deferentia  ; the  anus  ; kk,  ischiatic  protuberances. 

Fig.  1 9.  Internal  sexual  organs  seen  from  behind  ; d,  the  urinary  bladder  ; //, 
rectum  ; gg,  broad  ligaments  ; cc.  Fallopian  tubes. 


^ Med.  and  riiys.  Researches,  p.  19. 


476 


HERMAPHRODITISM. 


was  rather  large,  and  displayed  transverse  striae.  Traces  of  the 
nymphse  and  labia  externa  were  visible.  The  meatus  urinarius 
opened  beneath  the  pubis  into  the  vagina,  but  the  urine  must  have 
been  directed  along  the  groove  of  the  penis  by  the  membrane 
obstructing  the  orifice  of  the  vulva.  The  os  tincse  was  surrounded 
by  small  globular  glands.  The  orifice  and  neck  of  the  uterus 
admitted  a large  probe  into  the  cavity  of  that  organ,  which 
appeared  perfect  with  all  its  appendages.  The  round  and  broad 
ligaments,  together  with  well-developed  ovaries  (Fig.  19,  hb),  were 
all  found  in  situ.  The  scrotum  (Fig.  18,  c)  was  divided,  and  con- 
sisted of  a sac  on  each  side  of  the  labia  externa,  at  the  base  of  the 
penis,  covered  with  hair.  The  testicles  (Fig.  18,  dd)  lay  beneath 
the  skin  of  the  groin  about  two  inches  from  the  symphysis  pubis, 
obliquely  outwards  and  upwards  ; they  appeared  to  be  perfectly 
formed  with  the  epididymis,  //,  etc.  The  most  accurate  examination 
could  not  discover  vesicijlse  seminales ; but  an  opening  into  the 
vagina,  above  the  meatus  urinarius,  appeared  to  be  the  orifice  of 
the  vas  deferens.  In  all  other  respects,  the  male  and  female  organs 
of  generation  were  in  this  animal  as  completely  perfected  as  could 
have  been  anticipated  in  so  young  an  individual,  and  resembled  those 
of  other  individuals  of  a similar  age. 

Four  instances  are  now  on  record  of  the  alleged  co-existence  of 
male  testicles  and  female  ovaries  in  the  human  subject.  It  is  greatly 
to  be  regretted,  that  some  of  the  instances  have  not  been  so 
accurately  examined  in  their  anatomical  characters  as  their  import- 
ance demanded. 

a.  The  first  of  these  cases  is  detailed  by  Schrell.^  It  occurred 
in  an  infant  who  died  when  nine  months  old.  The  testes  and  all 
the  other  internal  and  external  male  organs  were  present  and  per- 
fectly formed,  with  the  exception  of  the  prepuce  of  the  penis,  which 
seemed  divided  in  front  and  rolled  up.  At  the  root  of  the  large 
penis  was  a small  vulva  or  aperture  capable  of  admitting  a pea,  and 
provided  with  bodies  having  an  appearance  of  labia  and  nymphse. 
This  vulva  led  into  a vagina  that  penetrated  through  the  symphysis 
pubis,  and  terminated  in  a nipple-like  body  or  imperfect  uterus,  to 
which  structures  having  a resemblance  to  the  Fallopian  tubes  and 
ovaries  were  attached. 

h.  A second  and  still  more  doubtful  case  of  the  alleged  existence 
of  both  testicles  and  ovaries  in  the  human  subject,  was  first  pub- 
lished by  Bedard.^  The  case  was  met  with  by  M.  Laumonier  of 
^ Schenck’s  Medic.  Chirurg.  ArcMv,  Bd.  i. 

2 Bullet,  de  la  Fac.  de  Med.  181.5,  p.  284  ; or  Diet,  des  Sc.  Med.  xxi.  p.  111. 


DOUBLE  HERMAPHRODITISM. 


477 


Eolien,  who  injected  and  dissected  the  sexual  parts,  and  deposited 
them  in  a dried  state,  along  with  a wax  model  representing  them  in 
their  more  recent  condition,  in  the  Museum  of  the  School  of 
Medicine  at  Paris.  In  the  wax  model,  two  female  ovaries,  with  a 
uterus,  vagina,  external  vulva,  and  large  imperforate  clitoris,  are 
seen  combined  with  two  male  testicles,  the  vasa  deferentia  of  which 
terminate  in  the  uterus  at  the  place  in  which  the  round  ligaments 
are  normally  situated  ; these  ligaments  themselves  are  wanting. 
The  preparation  of  the  dried  sexual  parts  is  far  from  being  ecpially 
satisfactory,  and,  in  its  present  imperfect  condition  at  least,  does 
not  bear  out  by  any  means  the  complete  double  hermaphroditic 
structure  delineated  in  the  model. 

c.  Dr.  Blackman  has  described  and  delineated  ^ a case  of  her- 
maphroditic malformation  in  an  adult  human  subject,  which  his 
statements  place  in  the  present  division.  The  external  genital 
organs  were  entirely  those  of  a male,  with  the  penis  large  and  per- 
forated, and  the  scrotum  of  a natural  appearance,  but  without 
testes.  Professor  Ackley,  of  Cleveland  Medical  College,  Ohio,  dis- 
sected the  body  after  death.  Internally  into  the  urethral  canal,  at 
the  neck  of  the  bladder,  there  opened  a contracted  vagina,  which 
communicated  above,  through  a normal  os  tincae,  with  a well-formed 
female  uterus.  From  the  upper  angles  of  the  uterus  there  set  off 
' two  perfect  and  permeable  Fallopian  tubes,  which  had  at  their 
fimbriated  extremities  two  ovaries  placed  in  their  usual  position.  In 
addition  there  were  found,  according  to  Dr.  Blackman’s  drawing  and 
description,  the  following  internal  male  organs,  namely,  two  testicles, 
situated  near  the  two  ovaries,  two  vasa  deferentia,  and  a prostate 
gland  of  the  natural  size  and  appearance.  The  vasa  deferentia,  or 
“ excretory  ducts  of  the  testes,  were  perfect,”  to  use  Dr.  Blackman’s 
own  Avords  ; but  he  omits  to  state  how  or  Avhere  they  terminated 
inferiorly.  It  is  greatly  to  be  regretted,  also,  that  there  is  no  ac- 
count given  of  the  internal  structure  of  the  tAvo  testes  and  two 
alleged  ovaries — a defect  which  it  is  to  be  hoped,  for  the  sake  of 
science,  that  he  or  Professor  Ackley  Avill  yet  supply.  The  stature 
of  this  malformed  being  Avas  large  ; the  external  configuration,  Avith 
the  exception  of  the  hips,  male ; the  beard  moderate  ; the  habits 
solitary,  Avith  a dislike  to  Avomen ; a discharge  like  menstruation 
occurred  monthly,  it  is  averred,  by  the  urethra,  and  Avas  attended 
Avith  much  suffering.  Death  occurred  during  one  of  these  men- 
strual periods  ; and  the  vagina  on  dissection  was  found,  according  to 
^ American  Journal  of  the  Medical  Sciences  for  July  1853,  p.  66. 


478 


HERMAPHEODITISM. 


Dr.  Blaclmian,  with  “ its  inner  surface  reddened ; and  its  cavity 
contained  menstrual  blood.” 

d.  Perhaps,  however,  the  most  complete  and  most  accurately 
detailed  case  of  double  hermaphroditism  hitherto  found  in  the 
human  subject,  is  one  dissected  by  Professor  Vrolik  of  Amsterdam 
in  1846.^  In  this  remarkable  instance  there  were  the  following 
male  and  female  organs  present — viz.,  on  the  left  side,  and  near 
each  other,  a testicle  and  an  ovary ; on  the  right  side  these  and 
other  parts  were  less  perfectly  developed  ; besides  there  existed  two 
rudimentary  Fallopian  tubes,  and  two  comparatively  more  perfect 
vasa  deferentia.  There  was  no  vestige  of  a male  prostate  gland  or 
vesiculiB  seminales  ; but  there  was  found  a female  uterus  and  vagina 
opening  interiorly  beneath  the  arch  of  the  pubis  into  a narrow  uro- 
genital canal,  which  ended  externally  at  the  root  of  an  impervious 
but  sulcated  penis  ; and  the  labia  externa  were  united  so  as  to  form 
an  apparently  perfect  male  scrotum,  the  right  side  of  which  was  en- 
larged by  the  presence  of  an  inguinal  hernia.  The  uterus  was  in 
its  normal  situation  between  the  bladder  and  rectum,  but  drawn 
obliquely  over  to  the  left  or  more  highly  developed  side.  It  was 
provided  and  fixed  with  the  usual  ligamenta  lata,  and  behind  with 
the  ligaments  of  Douglas.  The  cavity  of  the  uterus  was  mucous 
and  smooth  on  its  internal  surface,  and  it  ran  downwards — without 
any  formation  or  contraction  like  the  os  tincae  and  cervix  uteri — 
into  the  long  and  narrow  vagina.  The  walls  of  the  upper  portion 
of  the  vaginal  canal  were  thick,  and  its  mucous  surface  plicated ; 
inferiorly  this  canal  became  thinner  and  more  contracted,  especially 
where  it  terminated  in  the  urethra  or  common  uro-genital  tube. 
From  the  angles  of  the  fundus  uteri  imperfect  Fallopian  tubes  arose, 
and  ran  forwards  and  outwards  with  the  vasa  deferentia,  etc., 
through  the  inguinal  canals,  and  were  lost  upon  the  tunicae  vagi- 
nales.  On  the  right  side  the  vessels,  etc.,  running  to  tlie  ovary  and 
testicle,  were,  as  has  been  already  stated,  very  indistinct ; but  the 
left  testis  and  left  ovary  were  more  developed,  and  carefully  exa- 
mined by  Professor  Vrolik.  The  testis  on  this  side,  though  small 
in  size,  was  provided  with  a large  tunica  vaginalis.  When  divided, 
the  organ  did  not  show  the  tubuli  seminiferi,  but  its  characteristic 
transverse  septa  were  seen.  In  a glutinous  yellow  fluid  taken  from 
its  divided  tissue,  the  microscope  detected  small  nucleated  cells,  but 
no  true  spermatozoa.  The  testis  was  provided  with  its  usual  blood- 
vessels. The  vas  deferens,  after  leaving  it,  became  very  tortuous 
Tabiihc  ad  illustrandum  Emhryogcnesin  Hnminift  ct  ^[amma,Uuw,  tab.  xciv.  xcv. 


DOUBLE  IIEBMAPIIRODITISM. 


479 


for  a part  of  its  course,  and  then  ran  down  by  tlie  side  of  tlie  uterus 
and  vagina,  ultimately  opening  into  the  cavity  of  the  latter.  On 
the  opposite  and  less  developed  side,  it  is  worthy  of  remark  that 
the  more  rudimentary  right  vas  deferens  opened  into  the  afigle  of 
the  uterus.  Eeturning  to  the  left  ovary — this  organ  Avas  found 
lying  near  the  left  testicle,  and  of  an  oblong  form,  and  provided 
Avith  its  appropriate  and  characteristic  pampiniform  ])lexus  of  veins. 
The  internal  stroma  of  the  ovary  was,  at  the  circumference  of  the 
organ,  Avhite,  contracted,  and  indurated,  as  it  is  in  advanced  age, 
and  no  Graafian  vesicles  Avere  visible.  Further,  near  it  Avas  seen  a 
congeries  of  tubes,  analogous  to  the  sketch  given  by  Kobelt  of  the 
pro-ovarium.  The  subject  of  this  malformation  AA^as  58  years  old 
at  the  time  of  death.  At  17  years  of  age,  the  testes  began  to  de- 
scend through  the  inguinal  rings,  and  a copious  beard  appeared 
upon  the  face.  He  had  up  to  that  time  been  considered  a female, 
and  he  continued  to  dress  as  such  till  he  Avas  38  years  old.  At  that 
time,  three  medical  men — of  Avhom  Professor  A^rolik  Avas  one — exa- 
mined him,  and  gave  him  a certificate  that  he  Avas  a hypospadiaC 
or  malformed  male,  in  consequence  of  Avhich  he  subsequently  as- 
sumed the  male  attire — a conclusion  Avhich  seemed  to  be  further  cor- 
roborated by  the  absence  of  menstruation,  and  the  “ magna  in  sexum 
sequiorem  propensio.”  The  autopsy  showed,  hoAA^ever,  Iioay  difficult 
or  indeed  impossible  it  is,  during  life,  to  pronounce  always  decidedly 
and  correctly  on  the  actual  sex  of  such  malformed  individuals. 

HERMAPHRODITISM  AS  MANIFESTED  IN  THE  GENERAL  CONFORMATION 

OF  THE  BODY,  AND  IN  THE  SECONDARY  SEXUAL  CHARACTERS. 

INFLUENCE  OF  OVARIES  AND  TESTES  UPON  THEM. 

In  the  preceding  observations  Ave  have  princii)ally  confined 
ourselves  to  the  description  of  hermaphroditic  malformations  as 
seen  in  the  resemblance  in  appearance  and  structure  of  the  external 
genital  parts  of  one  sex  to  those  of  the  other,  and  in  the  different 
degrees  and  ATarieties  of  reunion  and  co-existence  of  the  reproduc- 
tive organs  of  the  two  sexes  upon  the  body  of  the  same  individual. 
Hermaphroditism,  hoAvever,  may  appear  not  only  in  Avhat  are 
termed  the  primary  sexual  parts  or  characters,  or,  in  other  Avords, 
in  the  organs  more  immediately  subservient  to  copulation  and  re- 
production, but  it  may  present  itself  also  in  the  secondary  sexual 
characters,  or  in  those  distinctive  peculiarities  of  the  sexes  that  are 
found  in  other  individual  parts  and  functions  of  the  economy,  as 


480 


HERMAPHRODITISM. 


well  as  in  the  system  at  large.  We  have  occasionally  an  oppor- 
tunity of  observing  some  tendency  to  a hermaphroditic  type  in 
the  general  system,  without  there  being  in  any  very  marked  corre- 
sponding abnormality  in  the  sexual  organs  themselves,  but  it  rarely 
happens  that  there  exists  any  hermaphroditic  malformation  of  the 
primary  organs  of  generation,  without  there  being  connected  with 
it  more  or  less  of  a hermaphroditic  type  in  the  secondary  sexual 
characters  ; and  this  circumstance  often  offers  us,  in  individual 
doubtful  cases,  a new  and  perplexing  source  of  fallacy  in  our 
attempts  to  determine  the  true  or  predominating  sex  of  the  mal- 
formed individual.  Before,  however,  describing  that  variety  of 
hermaphroditism  which  manifests  itself  in  the  general  system  and 
in  the  secondary  sexual  peculiarities,  it  will  be  necessary,  in  order 
to  understand  its  nature  and  origin,  to  premise  a few  remarks  on 
the  dependence  and  relation  of  these  secondary  characters  upon  the 
normal  and  abnormal  conditions  of  the  primary  sexual  organs. 

That  the  various  secondary  sexual  peculiarities  whicli  become 
developed  at  the  term  of  puberty  are  intimately  dependent  upon 
the  changes  that  take  place  at  the  same  period  in  the  organism  of 
the  female  ovaries  and  male  testicles,  seems  proved  by  various  con- 
siderations, particularly  by  the  effect  produced  by  original  defective 
development  and  acquired  disease  in  these  parts,  and  by  the  total 
removal  of  them  from  the  body  by  operation.  In  considering  this 
point,  I shall  speak  first  of  the  effects  of  the  state  of  the  ovaries 
upon  the  female  constitution,  and  shall  then  consider  those  of  the 
testicles  upon  the  male. 

When  the  usual  development  of  the  ovaries  at  the  term  of 
puberty  does  not  take  place,  the  secondary  sexual  characters  which 
are  naturally  evolved  in  the  female  at  that  period  do  not  present 
themselves ; and  this  deficiency  sometimes  occasions  an  approach  in 
various  points  to  the  male  formation.  Thus  in  a case  recorded  by 
Dr.  Pears,^  of  a female  who  died  of  a pectoral  affection  at  the  age 
of  twenty-nine,  the  ovaries  on  dissection  were  found  rudimentary 
and  indistinct,  and  the  uterus  and  Fallopian  tubes  were  present, 
but  as  little  developed  as  before  puberty.  This  individual  had 
never  menstruated,  or  showed  any  signs,  either  mental  or  corporeal, 
of  puberty.  The  mammse  and  nipples  were  as  little  developed  as 
those  of  the  male  subject.  She  had  ceased  to  grow  at  ten  years  of 
age,  and  had  attained  only  the  height  of  four  feet  six  inches. 


^ Phil.  Trails,  for  1805,  p.  225. 


SECONDAKY  SEXUAL  CHARACTERS. 


481 


In  another  analogous  instance  observed  by  Eenauldind  scarcely 
any  rudiments  of  the  ovaries  existed,  and  the  body  of  the  uterus 
was  absent,  but  the  external  genital  female  organs  were  well  formed. 
The  individual  who  was  the  subject  of  this  defective  sexual  develop- 
ment had  never  menstruated ; the  mammse  were  not  evolved  ; in 
stature  she  did  not  exceed  three  and  a half  French  feet ; and  her 
intellect  was  imperfectly  developed. 

In  reference  to  these  and  other  similar  instances  that  might  be 
quoted,^  it  may  be  argued  that  they  do  not  afford  any  direct 
evidence  of  the  evolution  of  the  sexual  characters  of  the  female 
depending  upon  that  of  the  ovaries,  as  the  arrestment  in  the 
development  of  both  may  be  owing  to  some  common  cause  which 
gives  rise  at  the  same  time  to  the  deficiency  in  the  development  of 
the  genital  organs,  and  to  the  stoppage  of  the  evolution  of  the  body 
in  general.  That  the  imperfection,  however,  in  the  organism  of  the 
ovaries  may  have  acted  in  such  cases  as  the  more  immediate  cause 
or  precedent  of  the  imperfection  or  non-appearance  of  the  secondary 
characters  of  the  sex,  seems  to  be  rendered  not  improbable,  in 
regard  to  some,  if  not  to  all  of  the  instances  alluded  to,  by  the  fact 
that  the  removal  of  these  organs,  before  the  period  of  puberty,  as  is 
seen  in  spayed  female  animals,  entails  upon  the  individuals  so 
treated  the  same  neutral  state  of  the  general  organisation  as  was 
observed  in  the  above  instances ; or,  in  other  words,  we  have  direct 
evidence  that  the  alleged  effect  is  capable  of  being  produced  by  the 
alleged  cause ; and  further,  when,  in  cases  of  operation  or  disease 
after  the  period  of  p|berty,  both  ovaries  have  happened  to  be 
destroyed,  and  their  influence  upon  the  system  consequently  lost, 
the  distinctive  secondary  characteristics  of  the  female  have  been 
observed  also  to  disappear  in  a greater  or  less  degree.  ' 

Thus,  in  the  well-known  case  recorded  by  Mr.  Pott,^  the 
catamenia  became  suppressed,  the  mammae  disappeared,  and  the 
body  became  thinner  and  more  masculine,  in  a healthy  and  stout 
young  woman  of  twenty- three  years  of  age,  whose  two  ovaries 
formed  hernial  tumours  at  the  inguinal  rings,  and  were,  in  conse- 

^ Seances  de  VAcad.  Eoy.  de  Ned.  28th  February  1826,  oxi^Mcdical  Repository 
for  1826,  p.  78. 

Davis,  in  his  Principles  and  Practice  of  Obstetric  Medicine,  p.  513,  refers  to 
several  instances  in  point.  We  may  mention  that  Dr.  Haighton  found  that  after 
the  Fallopian  tubes  were  divided  in  rabbits,  the  ovaries  became  gradually 
atrophied,  and  the  sexual  feelings  were  lost. — Phil.  Trans,  for  1787,  x>.  173. 

2 Surgical  Works,  vol.  iii.  p.  329. 


482 


H EPv  M APH  RODPn  SM. 


quence  of  their  incapacitating  the  patient  from  work,  both  removed 
by  operation. 

Many  facts  seem  to  show  that  the  act  of  menstruation  most 
probably  depends  upon  some  periodical  changes  in  the  ovaries,  or 
rather  in  the  Graafian  vesicles  of  these  organs  or  their  contents ; 
and  when  the  function  becomes  suddenly  and  permanently  stopped 
in  a woman  at  the  middle  period  of  life,  without  any  indications  of 
the  catamenial  fluid  being  merely  mechanically  retained,  we  may 
perha})s  suspect,  with  reasonable  probability,  the’  existence  of  a dis- 
eased state,  which  has  destroyed,  either  successively  or  simultaneously, 
the  functions  of  both  ovaries.  In  such  a case  the  distinctive 
secondary  peculiarities  of  the  female  sex  come  to  give  place  to  those 
of  the  male.  Thus  Vaulevier  mentions  an  instance  in  which  men- 
struation suddenly  ceased  in  a young  and  apparently  healthy 
woman  ; no  general  or  local  disease  followed ; but  soon  afterwards 
a perfect  beard  began  to  grow  upon  her  face.^  Again,  in  women 
who  have  passed  the  period  of  their  menstrual  and  child-bearing 
life,  and  in  whom  consequently  the  functions  and  often  the  healthy 
structure  of  the  ovaries  are  lost  or  destroyed,  we  have  frequently  an 
opportunity  of  observing  a similar  tendency  towards  an  assumption 
of  some  of  the  peculiarities  of  the  male ; an  increase  of  hair  often 
appears  upon  the  face,  the  mammae  diminish  in  size,  the  voice 
becomes  stronger  and  deeper  toned,  the  elegance  of  the  female 
form  and  contour  of  body  is  lost,  and  frequently  the  mind  exhibits 
a more  determined  and  masculine  cast.  Women,  both  young 
and  aged,  with  this  tendency  to  the  male  character,  are  repeatedly 
alluded  to  by  the  Koman  authors  under  the  name  of  vimgines  ; 
and  Hippocrates*  has  left  us  the  description  of  two  well-marked 
instances. 

Among  the  females  of  the  lower  animals  a similar  approach  to 
the  male  character  in  the  general  sj^stem  not  unfrequently  shows 

^ Journ.  de  Med.  tom.  Ixix.,  and  Meckel  in  Bd.  xi.  s.  275.  Meckel 

quotes  other  similar  cases  from  Seger  in  Ephcm.  Nat.  Car.  Dec.  i.  ann.  ix.  and  x. 
obs.  95  ; Vicat,  sur  la  Plique  Polonaise,  in  Murray’s  Pr.  Bihl.  Bd.  i.  s.  578  ; and 
Sclinrig’s  Parthenologia^  p.  184.  Burlin  published  an  express  treatise  on  the  sub- 
ject, Dc  B'lrhd  midierum  ex  vunstruorum  suppressionc,  Altorf,  1664.  See  also 
Haller’s  Elcm.  Phys.  tom.  v.  p.  32  ; Reuss,  B,epcrt.  Comment,  tom.  x.  p.  205  ; Eble, 
Die  Lchre  voa  den  Ilaaren  in  der  organischen  Natur.  Bd.  ii.  s.  222,  Vienna,  1831, 
and  Mehliss,  Ueber  Virilescenz  und  Rejv,venescenz  thierischcr  Korper,  Leipzic, 
1S38,  who  quotes  several  cases  additional  to  those  of  Meckel. 

2 De  Morb.  Vulg.  lib.  vi.  ss.  55,  56.  “ Abderis  Plnetusa,  Pythei  conjunx 

antea  per  juventam  foeciinda  erat ; viro  autem  ejus  exulante,  din  menses  defece. 
runt,  ex  quo  postea  dolores  et  rubores  ad  articulos  exorti  sunt.  Qiue  ubi  conti- 


VIRAGINES,  ETC. 


483 


itself  as  an  effect  both  of  disease  and  malformation  of  the  sexual 
organs,  and  also  in  consequence  of  the  cessation  of  the  powers  of 
reproduction  in  the  course  of  advanced  age.  Female  deer  are 
sometimes  observed  to  become  provided  at  puberty  with  the  horns 
of  the  stag,‘  and  such  animals  are  generally  observed  to  be  barren,^ 
probably  in  consequence  either  of  a congenital  or  acquired  morbid 
condition  of  their  ovaries  or  other  reproductive  organs.  In  old 
age,  also,  after  the  term  of  their  reproductive  life  has  ceased,  female 
deer  sometimes  acquire  the  horns  of  the  male  in  a more  or  less  per- 
fect degree  f and  Burdach  alleges  that  roes  sometimes  become  pro- 
vided with  short  horns  wlien  they  are  kept  from  the  male  during 
the  rutting  season,  and  at  the  same  time  furnished  with  abundant 
nourishment.*  Mehliss*  alludes  to  two  cases  in  which  a virilescent 
type  was  shown  principally  in  the  hair  of  the  female  deer.  In  one 
of  these  instances  the  hair  of  the  head,  neck,  and  abdomen,  the 
shape  of  the  ears  and  extremities,  and  the  odour  of  the  animal, 
gave  it  the  closest  resemblance  to  the  male,  and  it  followed  the  other 
females  as  if  urged  by  sexual  desire. 

This  kind  of  acquired  hermaphroditism  in  aged  females  has, 
however,  been  more  frequently  and  carefully  attended  to  as  it 
occurs  in  Birds  than  as  met  with  among  the  Mammalia,  tlie  change 
to  virilescence  in  the  former  being  more  marked  and  striking  than 
in  the  latter,  owing  to  the  great  difference  which  generally  exists 
betAveen  the  plumage  of  the  male  and  female.®  When  old  female 
birds  live  for  any  considerable  period  after  their  ovaries  have  ceased 
to  produce  eggs,  they  are  usually  observed  to  assume  gradually  more 
or  less  of  the  plumage  and  voice,  and  sometimes-  the  habits  also,  of 
the  male  of  their  own  species.  This  curious  fact,  first  pointed  out 

gerunt,  turn  corpus  virile  turn  universum  hirsutum  est  redditum,  bai’baque  est 
enata,  et  vox  aspera  reddita.  Sed  cum  omnia  quee  ad  menses  deducendos  facerent 
tentassemus,  non  profluxerunt,  verum  baud  ita  multo  post  vita  functa  est. 
Idem  quoque  in  Thaso  Narnysife  Gorgippi  conjugi  contigit.” — Hqypocr.  Op.  ed. 
Foesii,  p.  1201. 

^ Camden’s  Angl.  Norm.,  1603,  p.  821.  Langelot,  Eph.  Nat.  Cur.  Dec.  i. 
ann.  ix.  and  x.  obs.  88.  Ridinger’s  Abhild.  Scltencr  Thicre,  taf.  79  ; or  Meckel  in 
Reil’s  Archiv  fiir  die  Physiol.  Bd.  xi.  p.  273. 

^ Wildungen,  Taschenhuch  fiir  Forst-und  Jagd-freunde,  s.  17. 

® Otto’s  Path.  Anat.  by  South,  p.  166,  s.  123,  n.  18,  for  list  of  cases. 

^ Phys.  vol.  i.  § 183,  p.  318. 

® Ueber  Virilcscenz  thierisch.  Korper  ; or  British  and  Foreign  Medical  Itevitio, 
vol.  vi.  p.  77. 

® It  occurs  also  more  frequently  among  birds  than  among  mammalia,  from  the 
former  possessing  only  a single  ovary. 


484 


HERMAPHRODITISM. 


by  Aristotle*  in  relation  to  the  domestic  fowl,  has  now  been  seen  to 
occur  in  a number  of  other  species  of  birds,  but  particularly  among 
the  Gallinacese.  It  has  been  in  modern  times  remarked  in  the 
common  fowl  (Phasianus  gallus)  by  Tucker,  Butler,  and  Jameson ; 
in  the  common  pheasant  (P.  colchicus)  by  Hunter  and  Isidore  St. 
Hilaire ; in  the  golden  pheasant  (P.  pictus)  by  Blumenbach  and  St. 
Hilaire ; in  the  silver  pheasant  (P.  mjctemerus)  by  Bechstein  and  St. 
Hilaire ; in  the  turkey  {Mekagris)  by  Bechstein ; in  the  pea-hen 
(Pavo)  by  Hunter  and  Jameson;  and  in  the  partridge  {Tetrao  pc-r- 
drix)  by  Montagu  and  Yarrell.  Among  the  Cursores  it  is  men- 
tioned as  having  occurred  in  the  bustard  (Otis)  by  Tiedemann,  and 
in  the  American  pelican  (Platalea  aiaia)  by  Catesby.  In  the  order 
Palmipedse  it*has  been  observed  by  Tiedemann  and  Rumball  in  the 
domestic  and  wild  duck  [Anas  hosclia).  Among  the  Scansores  it 
has  been  seen  in  the  cuckoo  (Cucidus  canorus)  by  Payrandeau ; and 
among  the  Passeres  in  the  cotinga  (Ampelis)  by  Dufresne ; in  the 
chaffinch  {Fringilla)  and  rougequeiie  (Motacilla)  by  Prevost ; and  in 
the  bunting  (Emheriza  paradisea  and  longicauda)  by  Blumenbach. 

This  change  of  plumage  in  old  female  birds  commences,  accord- 
ing to  M.  Isidore  St.  Hilaire,*  much  sooner  in  some  instances  than 
in  others ; it  may  only  begin  to  show  itself  several  years  after 
the  bird  has  ceased  to  lay,  though  depending  more  or  less  directly 
upon  this  phenomenon,  and  sometimes  it  commences  immediately 
after  it.  The  change  may  be  effected  in  a single  season,  though  in 
general  it  is  not  complete  for  some  years.  When  it  is  perfected,  the 
female  may  display  not  only  the  variety  of  colours,  but  also  the 
brilliancy,  of  the  male  plumage,  which  it  sometimes  resembles  even 
in  its  ornamental  appendages,  as  in  the  acquisition  of  spurs,  and,  in 
the  domestic  fowls,  of  the  comb  and  wattles  of  the  cock.  The  voice 
of  the  bird  is  also  very  generally  changed.  Its  female  habits  and 
instincts  are  likewise  often  lost ; and,  in  some  instances,  it  has  been 
seen  to  assume  in  a great  degree  those  of  the  male,  and  has  even 
been  observed  to  attempt  coition  with  other  females  of  its  own 
species.^  In  most  of  the  female  birds  that  have  undergone  this 

^ “ Gallini,  cum  viceriiit  gallos,  concurnmt  maresque  imitanJi  suliagitare  co- 
iiantur.  Attollitur  etiam  crista  ipsis,  simul  et  dunes  (uropygium)  ; adeo  ut  jam 
non  facile  diagnoscantnr  an  foeminaj  sint.  Quibiisdam  etiam  calcaria  parva  surri- 
guntur.” — Hist.  Animal,  lib.  ix.  cap.  36. 

2 Edinburgh  Jour,  of  Philosoph.  Science,  1826,  p.  308. 

® Rumball,  in  Home’s  Comparative  Anatomy,  vol.  iii.  p.  330,  states  having 
observed  an  old  duck,  which  had  assumed  the  male  plumage,  attempt  sexual  con- 
nection Avith  another  female.  This  may  perhaps  enable  us  to  understand  the 


MALE  PLUMAGE  IN  FEMALE  BIUDS. 


485 


change,  the  ovary  has  been  found  entirely  or  partially  degenerated, 
though  in  a few  cases  the  morbid  alteration  is  not  very  marked, 
eggs  having  even  been  present  in  the  organ  in  one  or  two  instances. 
In  general,  however,  it  is  greatly  diminished  in  size,  or  has  become 
altogether  atrophied  ; but  the  perfection  of  the  change  in  the  plum- 
age does  not  seem  to  bear  any  direct  ratio  with  the  degree  of  mor- 
bid alteration  and  atrophy  in  the  ovary. 

That  the  change  towards  the  male  type,  described  as  occasionally 
occurring  in  old  female  birds,  is  directly  dependent,  not  upon  their 
age,  but  upon  the  state  of  their  ovaries,  seems  still  further  proved 
by  similar  changes  being  sometimes  observed  in  these  females  long 
previous  to  the  natural  cessation  of  the  powers  of  reproduction,  in 
consequence  of  their  ovaries  having  become  wasted  or  destroyed  by 
disease.  Greve,^  in  his  Fragments  of  Comjmrative  Anatomy  and  Phy- 
siology, states  that  hens  whose  ovaries  are  scirrhous  crow  sometimes 
like  cocks,  acquire  tail-feathers  resembling  those  of  the  male,  and 
become  furnished  with  large  spurs.  The  same  author  mentions  also 
the  case  of  a duck,  which,  from  being  previously  healthy,  suddenly 
acquired  the  voice  of  the  male,  and  on  dissection  whose  ovary  was 
found  hard,  cartilaginous,  and  in  part  ossified. 

Mr.  Yarrell,  in  a paper  read  before  the  Royal  Society  in  1827,* 
has  stated  that  in  a number  of  instances  he  had  observ^ed  young 
female  pheasants  with  plumage  more  or  less  resembling  the  male, 
and  in  all  of  them  he  found  on  dissection  the  ovaries  in  a very 
morbid  state,  and  the  oviduct  diseased  throughout  its  whole  length, 
with  its  canal  obliterated  at  its  upper  part.  He  also  shows  that  a 
similar  effect  upon  the  secondary  sexual  characters  of  the  female 
bird  is  produced  by  the  artificial  division  and  removal  of  a small 
portion  of  their  oviduct  in  the  operation  of  making  capons  of  female 
poultry;  and  he  states  that  his  investigations  have  led  him  to  be- 
lieve that  in  all  animals  bearing  external  characters  indicative  of 
the  sex,  these  characters  will  undergo  a change  and  exhibit  an 
appearance  intermediate  between  the  perfect  male  and  female, 
wherever  the  system  is  deprived  of  the  influence  of  the  true  sexual 

reputed  cases  of  liermapliroditism  in  women,  Avho,  as  related  by  Molleriis  {Tract, 
de  Hermaphr.  cap.  ii.)  and  Blancard  {Collect.  Medico-Phjs.  cent.  iii.  obs.  80\ 
after  having  themselves  borne  children,  became  addicted  to  intercourse  with  other 
females.  Of  course  we  cannot  give  our  credence  to  the  alleged  successful  issue  of 
such  intercourse. 

1 BriichstiXcke  sur  vergleich.  Anat.  unci  Physiol,  s.  45. 

2 Phil.  Trans,  for  1827,  part  ii.  p.  268. 


486 


HERMAPHRODITISM. 


organs,  whether  from  original  malformation,  acquired  disease,  or 
artificial  ohliteration.‘ 

From  the  frequency  with  which  castration  is  performed,  the 
effects  of  the  testicles  in  evolving  the  general  sexual  peculiarities  of 
the  male  have  been  more  accurately  ascertained  tlian' those  of  the 
ovaries  upon  the  female  constitution.  These  effects  vary  according 
to  the  age  at  which  the  removal  of  the  testicles  takes  i^lace.  When 
an  animal  is  castrated  some  time  before  it  has  reached  the  term  of 
puberty,  the  distinctive  characters  of  the  male  are  in  general  never 
developed;  and  the  total  absence  of  these  characters,  together  with 
the  softness  and  relaxation  of  their  tissues,  the  contour  of  their 
form,  the  tone  of  their  voice,  and  their  Avant  of  masculine  energy  and 
vigour,  assimilate  them  more,  in  appearance  and  habits,  to  the 
female  than  to  the  male  type.  If  the  testicles  are  removed  nearer 
the  period  of  puberty,  or  at  any  time  after  that  term  has  occurred, 
and  Avhen  the  various  male  sexual  peculiarities  have  been  already 
developed,  the  effect  is  seldom  so  striking;  the  sexual  instincts  of 
the  animal,  and  the  energy  of  character  Avhich  these  instincts  impart, 
are  certainly  more  or  less  completely  destroyed,  and  the  tone  of  the 
voice  is  sometimes  changed  to  that  of  puberty;  but  the  general 
male  characteristics  of  form,  such  as  the  beard  in  man,  and  the  horns 
in  the  Ituminantia,  most  commonly  continue  to  grow.  In  animals, 
such  as  the  stag,  which  possess  deciduous  horns,  the  removal  of  the 
testicles  during  the  rutting  season  causes  the  existing  horns  to  be 
permanent ; and  if  the  operation  is  performed  in  an  adult  animal 
Avhen  out  of  heat,  no  new  horns  in  general  appear.^  In  the  ox,  the 
effect  of  castration  upon  the  groAvth  of  the  horns,  even  ivhen  per- 
formed before  the  time  of  puberty,  is  quite  remarkable ; for,  instead 

^ On  old  or  diseased  female  birds  assuming  the  plumage,  etc.,  of  the  male,  see 
J.  Hunter,  Ohscrv.  on  the  An.  Econ.  p.  75  ; E.  Home,  Lect.  on  Comp.  Anat.  vol. 
iii.  p.  329  ; Mauduit,  in  Encycl.  Method.,  Art.  “ Faisan,”  tom.  ii.  p.  3 ; Butter,  in 
Wernerian  Soc.  Mem.  vol.  iii.  p.  183;  Schneider’s  Notes,  in  his  edition  of  the 
Emperor  Frederick  the  Second’s  Treatise  De  Arte  Venandi  cum  Avibus  ; 
Tucker’s  Ornithologia  Damnoniensis  ; Cateshy’s  Natural  History  of  Carolina,  etc., 
i.  t.  1 ; Bechstein,  Naturgeschichte  der  Deutschlands,  Bd.  ii.  sec.  116  ; Blumen- 
hach,  De  Anomalis  et  vitiosis  quihusdam  nisus  formativi  aberrationibus,  p.  8,  and 
Instil,  of  Physiology,  p.  369  ; Payrandeau,  Bull,  des  Sc.  Nat.  tom.  xiii.  p.  243  ; 
Tiedemann,  Zoologic,  vol.  iii.  p.  306  ; Geoff.  St.  Hilaire,  Phil.  Anat.  tom.  ii.  p. 
360  ; Isid.  St.  Hilaire,  Mem.  du  Mus.  d' Hist.  Nat.  tom.  xii.  p.  220  ; Annal.  des 
Sc.  Nat.  tom.  vii.  p.  336,  or  Edinburgh  New  Philosophical  Journal  for  1826,  p. 
302,  with  additional  cases  by  Professor  Jameson,  p.  309  ; Kob,  De  mutatione 
scxiis,  p.  11,  Berlin,  1823  ; Yarrel,  Phil.  Trans,  for  1827,  p.  268,  with  a drawing 
of  the  diseased  ovaries,  etc. 

^ Buffon,  Hist.  Nat.  tom.  vi.  p.  80. 


INFLUENCE  OF  OVARIES,  ETC. 


487 


of  having  their  development  altogether  stopped,  or  their  size  at  least 
diminished  by  the  operation,  as  occurs  in  the  ram  and  stag,  the 
volume  of  these  appendages  is  even  increased  by  it,  tlie  horns  of  the 
ox  being  generally  larger  but  less  strong  than  those  of  the  entire 
bull.  Castration  in  the  boar  causes,  according  to  Greve,^  the  tusks 
to  remain  small,  and  prevents  altogether  the  replacement  of  the 
teeth.  This  author  also  states  that  the  same  operation  on  Ihe  horse 
prevents  the  full  development  of  the  neck,  renders  the  teeth  smaller 
and  slower  in  their  growth,  increases  the  growth  of  the  hair,  and 
the  size  of  the  horny  protuberances  on  the  inside  of  the  legs.  The 
prostate  gland,  he  further  alleges,  as  well  as  the  vesiculse  seminales, 
become  augmented  as  much  as  a third  in  their  volume  in  con- 
sequence of  the  operation.' 

The  removal  of  the  testicles  both  before  and  after  the  period  of 
puberty  commonly  gives  rise  to  another  singular  effect — to  an  in- 
creased deposition  of  fat  over  the  body,^  and  from  this  circumstance 
the  general  form  of  the  body,  and  in  man  that  of  the  mammce,  is 
sometimes  modified  in  a degree  that  increases  the  resemblance  to 
the  opposite  sex.  In  the  sterile  of  both  sexes  in  the  human  subject 
an  unusual  corpulency  is  not  uncommon,  and  the  same  state  is  often 
met  with  in  old  persons,  and  particularly  in  females,  after  the  period 
of  their  child-bearing  life  is  past. 

The  nature  of  the  effects  produced  by  the  existence  and  func- 
tional activity  of  the  testicles  and  ovaries  upon  the  development  of 
the  secondary  sexual  characters  of  the  male  and  female,  may  be 
further  illustrated  by  what  occurs  in  the  season  of  heat  to  animals 
such  as  the  deer,  sheep,  birds,  etc.,  that  have  periodical  returns  of 
the  sexual  propensity.  At  these  periods  all  the  distinctive  general 
characters  of  the  sexes  become  much  more  prominently  developed, 
in  conjunction  with,  and  apparently  in  consequence  of,  the  changes 
which  have  been  ascertained  by  observation  to  occur  at  that  time  in 
the  relative  size  and  activity  of  the  internal  organs  of  generation. 
Thus  "with  the  return  of  the  season  of  sexuAl  instinct,  the  dorsal 
crests  and  cutaneous  earlobes  of  tritons  enlarge;  in  Batrachian  rep- 
tiles the  spongy  inflations  of  the  thumbs  become  increased  in  size-; 
the  various  species  of  singing  birds  re-acquire  their  vocal  powers ; 
and  some,  as  the  cuckoo  and  quail,  appear  capable  of  exercising  their 
voice  only  at  this  period  of  the  year.  At  the  pairing  season  also 
the  plumage  of  birds  becomes  brighter  in  tint,  and  in  some  instances 

^ Bruclistiicke  zur  Vergl.  Anat.  wid  Physiol,  p.  41.  ^ Ibid.  p.  45. 

® See  Cyclop,  of  Anat.  and  Phys.,  Art.  “Adipose  Tissue.” 

87 


488 


HEEMAPHRODITISM. 


is  in  other  respects  considerably  changed,  as  in  the  male  ruff  (Tringa 
pugnax),  which  then  re-assumes  the  tuft  of  feathers  upon  his  head 
and  neck,  and  the  red  tubercles  upon  his  face,  that  had  fallen  off 
during  the  moulting,  and  thus  left  him  more  nearly  allied  in  appear- 
ance to  the  female  during  the  winter.  In  reference  to  this  subject, 
it  appears  to  us  interesting  to  remark,  that  in  certain  birds,  as  in  the 
different'species  of  the  genus  Fringilla,  the  male  presents  in  winter 
a plumage  very  similar  to  that  of  the  female,^  and  in  the  present 
inquiry  it  is  important  to  connect  this  fact  with  the  very  diminutive 
size  and  inactive  condition  of  the  testicles  of  these  birds  at  that 
season. 

From  the  remarks  that  we  have  now  made  upon  the  influence  of 
the  ovaries  and  testicles  in  developing  the  general  sexual  peculiari- 
ties of  the  female  and  male,  it  will  be  easy  to  conceive  that  when, 
in  cases  of  malformation  of  the  external  genital  organs  giving  rise  to 
the  idea  of  hermaphroditism,  there  is  at  the  same  time,  as  sometimes 
happens,  a simultaneous  want  of  development  in  the  internal  organs 
of  reproduction,  particularly  in  the  ovaries  and  testicles,  the  general 
physical  and  moral  peculiarities  distinctive  of  the  sex  of  the  indi- 
vidual may  be  equally  deficient,  or  have  a tendency  even  to  approach 
in  more  or  fewer  of  their  points  to  those  of  the  opposite  sexual  type. 
In  this  way  we  may,  it  is  obvious,  have  general  or  constitutional 
hermaphroditic  characters,  if  they  may  be  so  termed,  added  to  those 
already  existing  in  the  special  organs  of  generation,  and  rendering 
more  difficult  and  complicated  the  determination  of  the  true  sex  of 
the  malformed  individual.  Some  cases  of  spurious  hermaphroditism 
in  the  male,  published  by  Sir  E.  Home,^  may  serve  to  illustrate  this 
remark. 

A marine  soldier,  aged  twenty- three,  was  admitted  a patient  into 
tlie  Eoyal  Naval  Hospital  at  Plymouth.  He  had  been  there  only  a 
few  days,  when  a suspicion  arose  of  his  being  a woman,  which  in- 
duced Sir  Everard  to  examine  into  the  circumstances.  He  proved 
to  have  no  beard ; his  breasts  were  fully  as  large  as  those  of  a 
woman  at  that  age ; he  was  inclined  to  be  corpulent ; his  skin  was 
uncommonly  soft  for  a man  ; his  hands  were  fat  and  short,  and  his 
thighs  and  legs  very  much  like  those  of  a woman ; the  quantity  of 
fat  upon  the  os  pubis  resembled  the  mons  veneris ; and  in  addition 
he  v/as  v/eak  in  his  intellect,  and  deficient  in  bodily  strength.  The 
external  genital  organs  showed  him  to  be  a male,  but  the  penis  was 

^ Stark’s  Elements  of  Nat.  Hist,  vol.  i.  p.  243. 

^ Comp.  Anat.  vol.  iii.  p.  320. 


INFLUENCE  OF  OVAKIES,  ETC. 


489 


iinusucally  small,  as  well  as  short,  and  not  liable  to  erection ; the 
testicles  were  not  larger  in  size  than  they  commonly  are  in  the 
foBtal  state ; and  he  had  never  felt  any  passion  for  the  opposite  sex. 

The  following  cases  by  the  same  author  strongly  illustrate  this 
subject.^  In  a family  of  three  children  residing  near  Modlmry  in 
Devonshire,  the  second,  a daughter,  was  a well-formed  female,  the 
eldest  and  youngest  were  both  malformed  males.  The  eldest  Avas 
thirteen  years  of  age.  His  mons  A^eneris  Avas  loaded  Avith.fat;  no 
penis  could  be  said  to  be  present,  but  there  Avas  a prseputium  a sixth 
of  an  inch  long,  and  under  it  the  meatus  urinarius,  but  no  vagina. 
There  Avas  an  imperfect  scrotum  Avith  a smooth  surface,  there  being 
no  raphe  in  the  middle,  but,  in  its  place,  an  indented  line ; it  con- 
tained tAvo  testicles,  of  the  size  met  Avith  in  the  foetus.  His  breasts 
were  as  large  as  those  of  a fat  woman.  He  Avas  four  feet  high,  and 
of  an  uncommon  bulk,  his  body  round  the  AA^aist  being  equal  to  that 
of  a fat  man,  and  his  thighs  and  legs  in  proportion.  He  Avas  very 
dull  and  heaA^y,  and  almost  an  idiot,  but  could  walk  and  talk ; he 
began  to  Avalk  Avhen  a year  and  a half  old.  The  younger  brother 
Avas  six  years  old,  and  uncommonly  fat  and  large  for  his  age.  He- 
Avas  more  an  idiot  than  the  other,  not  having  sense  enough  to  learn 
to  Avalk,  although  his  limbs  Avere  not  defective. 

A case  in  a similar  manner  confirmatory  of  the  preceding  remarks 
is  mentioned  by  Itard  de  Riez.^  A young  man,  aged  tAventy-three, 
had  no  testes  in  the  scrotum,  a very  small  penis,  not  capable  of 
erection,  and  a divided  scrotum.  He  Avas  in  stature  beloAV  the 
middle  size.  His  skin  Avas  soft,  smooth,  and  entirely  free  from  hair, 
the  place  of  the  beard  being  supplied  by  a slight  doAvn.  The  voice 
Avas  hoarse ; the  muscles  Avere  not  Avell  marked ; the  form  of  the 
chest  resembled  that  of  the  female,  and  the  pelvis  Avas  extremely 
broad  and  large.  The  intellectual  faculties  Avere  very  dull,  and  the 
sexual  appetite  Avas  entirely  Avanting. 

Renauldin,  also,  in  the  same  Avork,^  has  recorded  another  case  in 
point.  In  a soldier  of  tAventy-four  years  of  age,  Avhose  genital  organs 
Avere  extremely  undeveloped,  his  penis  being  only  of  the  size  of  a 
small  tubercle,  and  his  testicles  not  larger  than  small  nuts,  the  pelvis 
Avas  broad the  chest  narroAV  ; the  face  and  body  in  general  Avere  not 
covered  Avith  hair,  Avith  the  exception  of  a small  quantity  upon  the 
pubis ; the  voice  AA'as  feminine,  and  the  mammary  glands  Avere  as 

^ Comp.  Anat.,  pp.  320-21. 

* Memoircs  de  la  Societe  Med.  d' Emulation,  tom.  iii.  pp.  293-95. 

" Thid.  tom.  i.  p.  241. 


490 


HERMAPHRODITISM. 


perfectly  developed  as  in  the  adult  female.  The  body  of  this  indi- 
vidual was  rather  lean  than  otherwise.  The  mammae  had  begun  to 
enlarge  when  his  body  attained  to  its  full  stature  at  sixteen  years  of 
age.  He  had  all  the  habits  and  sexual  desires  of  the  male  sex. 

In  quadrupeds,  as  in  man,  when  the  testicles  or  ovaries  are  im- 
perfectly formed,  the  secondary  sexual  peculiarities  are  frequently  so 
defectively  evolved  as  to  offer  a kind  of  hermaphroditic  or  neutral 
type  in  the  general  configuration  and  characters  of  the  animal. 
Thus,  the  free-martin  does  not  present  an  exact  analogy  in  form 
either  with  the  bull  or  cow,  but  exhibits  a set  of  characters  inter- 
mediate between  both,  and  more  nearly  resembling  those  of  the  ox 
and  of  the  spayed  heifer.  In  size  it  resembles  the  castrated  male  and 
spayed  female,  being  considerably  larger  than  either  the  bull  or  the 
cow,  and  having  horns  very  similar  to  those  of  the  ox.  Its  bellow 
is  similar  to  that  of  the  ox,  being  more  analogous  to  that  of  the  cow 
than  of  the  bull.  Its  flesh,  like  that  of  the  ox  and  spayed  heifer,  is 
generally  much  finer  in  its  fibre  than  the  flesh  of  either  the  bull  or 
cow,  and  is  supposed  to  exceed  even  that  of  the  ox  and  heifer  in 
• delicacy  of  flavour.! 

The  consideration  of  the  various  facts  that  we  have  now  stated 
inclines  us  to  believe  that  the  natural  history  characters  of  any  . 
species  of  animal  are  certainly  not  to  be  sought  for  solely  either  in 
the  system  of  the  male  or  in  that  of  the  female  ; but,  as  Mr.  Hunter 
pointed  out,  they  are  to  be  found  in  those  properties  that  are  common 
to  both  sexes,  and  which  we  have  occasionally  seen  combined 
together  by  nature  upon  the 'bodies  of  an  unnatural  hermaphrodite,  or 
evolved  from  the  interference  of  art  upon  a castrated  male  or  spayed 
female.  In  assuming  at  the  age  of  puberty  the  distinctive  secondary 
peculiarities  of  his  sex,  the  male,  so  far  as  regards  these  secondary 
peculiarities,  evidently  passes  into  a higher  degree  of  development 
than  the  female,  and  leaves  her  more  in  possession  of  those  characters 
that  are  common  to  the  young  of  both  sexes,  and  which  he  himself 
never  loses  when  his  testicles  are  early  removed.  These  and  other 
facts  connected  with  the  evolution  of  both  the  primary  and  second- 
ary peculiarities  of  the  sexes  further  appear  to  us  to  show  that, 
physiologically  at  least,  we  ought  to  consider  the  male  type  of 
organisation  to  be  the  more  perfect  as  respects  the  individual, 
and  the  female  the  more  perfect  as  respects  the  species.  Hence 
we  find  that,  when  females  are  malformed  in  the  sexual  parts  so 
^ Hunter’s  Ohs.  on  the  An.  Econ.,  p.  6C 


SECONDARY  SEXUAL  CHARACTERS. 


491 


as  to  resemble  the  male,  the  malformation  is  almost  always  one 
of  excessive  development,  as  enlargement  of  the  clitoris,  union  of 
the  labia,  etc. ; and,  on  the  other  hand,  when  the  male  organs  are 
malformed  in  such  a manner  as  to  simulate  the  female,  the  abnormal 
appearance  is  generally  capable  of  being  traced  to  a defect  of  deve- 
lopment, such  as  the  want  of  closure  of  the  perineal  fissure,  and  of 
the  inferior  part  of  the  urethra,  diminutive  size  of  the  penis,  reten- 
tion of  the  testicles  in  the  abdomen,  etc.  In  the  same  way,  when 
the  female  assumes  the  secondary  characters  of  the  male,  it  is  either, 
first,  when  by  original  malformation  its  own  ovaries  and  sexual 
organs  are  so  defective  in  structure  as  not  to  be  capable  of  taking 
a part  in  the  function  of  reproduction,  and  of  exercising  tliat 
influence  over  the  general  organisation  which  this  faculty  imparts 
to  them ; or,  secondly,  when  in  the  course  of  age  the  ovaries  have 
ceased  to  be  capable  of  performing  the  action  allotted  to  them  in 
the  reproductive  process.  In  both  of  these  cases  we  observe  the 
powers  of  the  female  organisation,  now  that  its  capabilities  of  per- 
forming its  particular  office  in  the  continuation  of  the  species  are 
wanting  or  lost,  expanding  themselves  in  perfecting  its  own  indi- 
vidual system ; and  hence  the  animal  gradually  assumes  more 
or  fewer  of  those  secondary  sexual  characters  that  belong  to  the 
male. 

We  do  not  consider  it  subversive  of  the  preceding  view  to 
qualify  it  with  the  two  following  admissions — Is^,  that  owing  to 
the  energies  of  the  female  system  being  so  strongly  and  constantly 
directed  towards  the  reproductive  organs,  and  the  accomplishment 
of  those  important  functions  which  these  organs  have  to  perform  in 
the  economy  of  the  species,  the  general  characters  of  the  species 
may  be  developed  in  her  body  in  a degree  less  than  they  otherwise 
would  be,  or  than  actually  constitutes  the  proper  standard  of  the 
species ; and,  2dlij,  that,  in  consequence  of  the  peculiarities  of  the 
sexual  functions  of  the  female,  some  of  the  individual  organs  of  her 
system,  as  the  mammae,  are  evolved  in  a degree  greater  than  is  con- 
sonant with  the  standard  characters  of  the  species.  At  the  same  time 
we  would  here  remark  that  the  occasional  enlarged  condition  of  the 
mammae  in  hermaphrodites  in  whom  the  male  sexual  type  of  structure 
predominates  (as  in  the  examples  of  spurious  male  hermaphrodites 
that  have  been  quoted  from  Sir  E.  Home,  and  in  those  mentioned 
by  Eenauldin,  Julien,  Petit,  Rullier,  and  others  in  the  human  sub- 
ject, as  well  as  in  numerous  cases  among  hermaphrodite  quadrupeds), 
would  almost  seem  to  show  that  the  full  development  of  the  mam- 


492 


HERMAPHRODITISM. 


mary  glands  is  a character  proper  to  the  species  in  general,  rather 
than  one  peculiar  to  the  female  system  alone.  In  males,  also,  who 
are  perfect  in  their  reproductive  organs  and  functions,  the  mammae 
are  sometimes  observed  to  be  developed  in  so  complete  a manner  as 
to  be  capable  of  secreting  milk,  forming  what  may  be  regarded  as 
one  of  the  slightest  approaches  towards  hermaphroditic  malformation 
in  the  male  organisation;^  and  the  mammae  of  the  infants  of  both 
sexes  not  unfrequently  contain  a lactiform  fluid  at  birth. 


LATERAL  HERMAPHRODITISM,  ETC.,  IN  THE  EXTERNAL  OR  SECONDARY 
SEXUAL  CHARACTERS  OF  THE  BODY. 

In  some  instances  of  hermaphroditic  malformation,  the  total 
form  and  configuration  of  the  body  have  been  alleged  to  present 
not  only  a general  tendency  towards  the  physical  secondary  cha- 
racters of  the  opposite  sex,  or  to  exhibit  in  a permanent  state  the 
neutral  condition  existing  before  puberty,  but  different  individual 
parts  of  it  have  been  occasionally  conceived  to  be  developed  after  a 
different  sexual  type.  Thus,  for  instance,  we  have  already  men- 
tioned in  regard  to  Hubert  Jean  Pierre,  that  the  upper  half  of  the 
body  of  this  individual  seemed  form.ed  after  the  female,  and  the 
lower  half  after  the  male  type,  the  larynx  and  mammse  being  quite 
feminine,  the  face  showing  no  appearance  of  beard,  and  the  arms 
being  delicate  and  finely  rounded,  while  the  pelvis  was  narrow,  and 
the  thighs  were  marked  and  angled  as  in  man.  In  a case  described 
by  Schneider*  the  reverse  held  true,  the  bust  being  male  with  a 
strong  beard  and  large  thorax,  and  the  pelvis  being  large  and  dis- 
tinctly female.  A more  mixed  combination  of  the  secondary  sexual 
characters  has  been  already  described  as  existing  in  the  cases  detailed 
by  Picco,  Mayer,  Arnaud,  Bouillaud,  etc.  etc. 

^ The  secretion  of  milk  in  the  mammary  glands  of  the  male  is  occasionally 
observed  amongst  our  domestic  quadrupeds.  See  Gurlt’s  Pathologischen  Anatamie 
der  Hrms-Smujthiere,  Btl.  ii.  s.  188  ; Blumenbach  in  the  Hanovcrisch  Magazin  for 
1787  ; and  Home  in  Comp.  Anat.  iii.  p.  328.  Among  the  recorded  instances  and 
observations  upon  it  in  man  we  may  refer  to  Paullini,  Cyiiogrcqdiia,  p.  52  ; Scha- 
cher,  Dc  Lacte  Virorum  ct  Virginiivi,  Leipz.  1742  ; Sinnibaldus,  Gcnmntlirop. 
tom.  iv.  p.  456  ; Alex.  Benedictus,  Anatom.  Corp.  Hum.  lib.  iii.  p.  595  ; Winslow, 
Anatomy,  vol.  ii.  p.  214  ; Deusing,  Dc  Lacte,  p.  327  ; Kyper,  Anthropologia,  lib. 
i.  p.  490  ; Buffon,  Hist.  Nat.  tom.  ii.  p.  543  ; Bishop  of  Cork,  Phil.  Trams,  vol. 
xli.  p.  813  ; Humboldt,  Personal  Narrative,  vol.  iii.  p.  57  ; Franklin,  First  Expe^ 
dition  to  the  Polar  Seas,  London,  1823,  p.  157. 

^ Kopp’s  Jahrbiich  dcr  Staatsarzneikundc,  Bd.  x.  s.  134. 


ONE  SIDE  MALE,  THE  OTHER  FEMALE. 


493 


One  side  of  the  body  has  been  sometimes  observed  to  be 
apparently  formed  in  one  or  more  of  its  parts  on  a sexual  type 
different  from  that  of  the  same  parts  on  the  opposite  side.  Girald, 
in  his  Topography  of  Ireland,^  mentions  a reputed  female,  who  had 
the  right  side  of  the  face  bearded  like  that  of  a man,  and  the  left 
smooth  like  that  of  a woman.  Mr.  King^  has  described  an  interest- 
ing instance  of  hermaphroditic  malformation  in  an  individual  whose 
general  character  w'as  masculine,  but  wuth  the  pelvis  large  and  wide  ; 
the  left  testicle  only  had  descended  into  the  groin,  and  the  mamma 
of  this  side  was  small  comparatively  to  that  of  the  opposite  or 
right  side. 

In  a hind  mentioned  by  Mr.  Hay,®  and  which,  he  believed,  had 
never  produced  any  young,  one  of  the  ovaries  on  dissection  after 
death  was  found  to  be  scirrlious.  The  animal  had  one  horn  resem- 
bling that  of  a three-years-old  stag  on  the  same  side  with  the  dis- 
eased ovary  ; there  w'as  no  horn  on  the  opposite  side.  Bomare^ 
has  given  a similar  case  in  the  same  animal,  Avhere  a single  horn 
was  present,  situated  also  on  the  same  side  with  the  diseased  and 
degenerated  ovary ; and  Bussell®  states,  as  the  result  of  his  experi- 
ments on  castration  in  the  deer,  that  when  he  removed  one  testicle 
only  from  the  animal,  the  horn  on  the  opposite  side  was  the  more 
completely  developed  of  the  two.  Azara®  observed  in  two  birds 
the  right  side  of  the  tail  to  possess  the  characters  of  the  male,  and 
the  left  those  of  the  female. 

In  the  hermaphroditic  lobster  previously  alluded  to  as  de- 
scribed by  Nicholls,  the  general  external  configuration  of  the  body 
was,  like  that  of  the  sexual  organs,  perfectly  female  on  one  side, 
and  perfectly  male  on  the  other. 

It  is  principally,  however,  among  hermaphroditic  insects  that  a 
difference  of  sexual  type  in  the  general  conformation  of  the  opposite 
sides  of  the  body,  and  of  its  individual  parts,  has  been  observed ; 
and  this  malformation  is  the  more  striking  and  easy  of  observation 
in  this  class  of  animals,  on  account  of  the  great  differences  in  colour, 
size,  and  form  respectively  presented  by  the  antennae,  wings,  and 
other  parts  of  the  body,  of  the  males  and  females  of  the  same 
species. 

^ Topog.  Hihernim,  in  Camden's  Angl.,  etc.,  1603,  part  ii.  p.  7*24. 

London  Medical  Repository  for  1820,  vol.  xiii.  p.  87. 

® Linnoean  Transactions,  vol,  iii.  p.  356.  Journ.  de  Rhys.  tom.  vi.  p.  506. 

® Economy  of  Kcitiirc  in  Glandular  Diseases. 

® KoL’s  Dissert,  de  Mutatione  ScxUs,  p.  19. 


494 


HERMAPHRODITISM. 


Lateral  hermaphroditism  of  the  body  in  Insects  has  been  most 
frequently  observ^ed  by  entomologists  amongst  the  class  Lepidop- 
tera.  It  has  now  been  remarked  in  the  following  species  : — In  the 
Argijnnis  Lymna  alexls,  Saturnia  pijri,  Endrornis  versicolor^ 

and  Harpya  vinula  (Ochsenheimer) ; in  the  Gastrophaga  medicagmis 
and  Lyccena  adonis  (Rudolphi) ; in  the  Liparis  dispar  (Schaefer, 
Ochsenlieimer,  and  Rudolphi) ; in  the  Saturnia  Carpini  (Capieux, 
Ochsenheimer,  and  Rudolphi) ; in  th-e  Gastrophaga  guercifolia  (Hett- 
linger  and  Rudolphi) ; in  the  Gastrophaga  pini  (Scopoli) ; in  the 
Gastrophaga  cratcegi  (Esper) ; in  the  Sphinx  convolvuli  (Ernst) ; Sphinx 
popidi  (Fischer  and  Westwood) ; Papilio  polycaon  (Macleay)  ; Polyom- 
mahis  alexis  (Entomolog.  Mag.,  vol.  iii.  p.  304) ; Bomhyx  castrensis 
(Duval) ; in  the  Argynnis  paphia  (Allis)  ; in  the  Vanessa  atalanta 
(Schrank  and  Germar)  ; and  in  the  Vanessa  antiopha  and  Deilephila 
euphorhm  (Germar).  King  and  Germar  have  recorded  two  instances 
of  it  among  the  Coleoptera — the  former  in  the  Lucanus  cervus,  and 
the  latter  in  the  Melolontha  vulgaris  ; and  Mr.  Westwood  mentions 
a third  case  in  the  large  water-beetle  (Dytiscus  marginalis),  as  con- 
tained in  Mr.  Hope’s  collection,  any  has  seen  a fourth  in  the  stag- 
beetle  {Lucanus  cervus). 

Out  of  twenty-nine  recorded  cases  of  lateral  hermaphroditism 
in  Insects,  in  which  the  sexual  characters  of  each  side  are  distinctly 
specified,  I find  that  in  seventeen  instances  the  right  side  was  male, 
and  in  twelve  female.  Burmeister  alleges  that  in  by  far  the  majority 
of  cases  the  right  side  is  male,  and  the  left  female — a statement  in 
which  Meckel  coincides,  wdiile  Westwood  maintains  the  reverse. 
The  cases  I have  myself  collected  are  certainly  numerically  in  favour 
of  the  former  opinion,  but  the  data  are  as  yet  so  few,  and  the  differ- 
ence so  trifling,  as  not  to  w^arrant  any  decided  conclusion  on  this 
point. 

In  some  instances  we  find  among  insects  an  imperfect  lateral 
hermaphroditism  consisting  of  some  parts  of  one  side,  as  of  one  or 
more  of  the  wings,  palpi,  or  antennae,  being  formed  according  to  a 
different  sexual  type  from  the  same  parts  of  the  opposite  side,  and 
from  the  general  body  of  the  animal.  Thus  in  the  Melitcea  described 
and  dissected  by  King  (see  page  434),  the  general  form  of  the 
insect  was  male,  but  the  left  eye,  palpus,  antenna,  and  left  sexual 
fang,  were  smaller  than  in  individuals  belonging  to  this  sex  ; the 
left  antenna  was  annulated  with  white  and  yellow  at  the  apex,  while 
the  right  w^as  of  one  colour ; the  general  form  of  the  abdomen  was 
male,  but  somewhat  thick,  and  the  wings  were  all  equal  and  male. 


LATERAL  HERMAPHRODITISM  IN  INSECTS. 


495 


In  a Pontia  du'plidlce  mentioned  by  Rudolplii,  and  wliich  in  its 
general  external  characters  was  female,  the  right  anterior  wing  was 
formed  after  the  male  type,  and  the  sexual  organs  also  resembled 
those  of  the  male. 

Oclisenheimer  mentions  a Gastrophaga  qiiercus  with  the  body 
and  the  antennae  and  wings  on  the  left  side  female,  and  the  right 
wings  male  ; and  a second  with  the  body  and  the  right  side  female, 
and  the  left  side  and  two  antennae  male,  the  latter  being  brown  and 
pectinated. 

In  this  imperfect  variety  of  lateral  hermaphroditism,  the  mal- 
formed wing,  antenna,  or  palpus,  is  sometimes  formed  after  one 
sexual  type  and  coloured  after  another.  In  a male  Melikea  qjhcdje 
noticed  by  Germar,  the  right  wings  and  antenna  were  female  in  re- . 
gard  to  size,  but  male  in  respect  to  colouring  and  markings.  In  a 
female  Deilephila  galii  he  found  the  left  antenna  and  palpus  of  the 
small  size  of  the  male,  but  agreeing  in  colouring  and  markings  with 
the  corresponding  female  parts  on  the  right  side.  In  a Pontia 
caradmines,  which  was  male  in  all  its  other  characters,  Oclisenheimer 
observed  the  right  superior  wing  marked  as  in  the  female,  and  he 
mentions  another  individual  of  the  same  species  which  had  a female 
form  with  some  male  colours. 

In  another  variety  of  insect-hermaphroditism  the  sexual  differ- 
ence is  sometimes,  as  we  have  already  noticed  in  regard  to  the 
human  subject,  expressed  not  by  a lateral  but  by  a longitudinal 
sexual  antagonism,  or,  in  other  words,  the  anterior  and  posterior 
parts  of  the  body  are  formed  after  the  two  opposite  sexual  types. 
Thus  in  a Saturnia  carpini  described  by  Oclisenheimer,  the  antennae 
were  male,  the  superior  wings  male  in  form,  but  coloured  as  in  the 
female,  and  the  posterior  wings,  with  the  exception  of  a reddish 
brown  spot  upon  the  left,  were,  with  the  body  and  other  parts, 
female. 

Lastly,  in  a third  variety  of  external  hermaphroditic  conforma- 
tion in  Insects,  we  find  the  characters  of  the  two  sexes  mixed  up 
and  crossed  in  different  irregular  combinations  upon  the  body  of  the 
same  individual.  In  a Gastroptliaga  castrensis  described  by  Rudolphi, 
and  where  the  male  type  predominated,  with  a tendency,  however, 
in  all  parts  to  the  female  form,  the  right  antenna  and  the  wings  on 
the  opposite  or  left  side  were  distinctly  female,  while  the  left 
antenna  and  right  wings  were  entirely  male,  the  latter  being  only 
somewhat  larger  than  in  male  insects,  and  the  colours  brighter  than 
in  the  female.  In  a Bomhyx  castrensis  alluded  to  by  Westwood,  the 


496 


HEEMAPHPtODITISM. 


wings  on  the  right  side,  and  the  antennae  and  abdomen  of  the  left, 
were  those  of  a male,  while  the  left  wing,  right  antennae,  and  right 
side  of  the  abdomen,  were  those  of  a female. 

GENERAL  SUMMARY  WITH  REGARD  TO  THE  NATURE  OF  THE 
VARIETIES  OF  SPURIOUS  HERMAPHRODITISM. 

On  some  of  the  varieties  of  spurious  hermaphroditism  it  is  un- 
necessary for  us  to  dwell  here.  For  instance,  the  first  species  of 
spurious  male  hermaphroditism,  or  that  arising  from  extroversion  of 
the  urinary  bladder,  is  acknowledged  by  all  to  be  merely  one  of  the 
many  varieties  of  arrested  development  or  conjunction  in  the  median 
line  of  the  body,  and  so  need  not  detain  us.  Two  other  forms — 
namely,  the  second  female  species  consisting  of  prolapsus  of  the 
uterus,  and  tlie  second  male  consisting  of  an  adhesion  of  the  penis 
to  the  scrotum — seem  both  referable  to  the  head  rather  of  disease 
than  of  original  malformation.  This  latter  indeed  appears  in  all  , 
probability  only  an  efiect  or  result  of  adhesive  inflammatory  action 
in  the  affected  parts  during  embryonic  or  foetal  life.  Both  of  the 
two  remaining  forms  of  spurious  hermaphroditism — viz.,  those  con- 
sisting of  hypospadiac  fissure  of  the  urethra,  scrotum,  and  perineum 
in  the  male,  and  of  abnormal  magnitude  of  the  clitoris  in  the  female 
— seem  readily  explicable  upon  the  doctrine  of  arrestment  and 
abnormality  in  the  development  of  the  malformed  parts. 

We  have  already  described  at  sufficient  length  the  process  of 
development  of  the  different  copulative  organs,  and  have  shown  that 
those  various  degrees  of  hypospadiac  malformation  which  constitute 
the  common  form  of  spurious  hermaphroditism  in  the  male,  may  be 
traced  to  arrestment  of  this  process  at  various  periods  or  stages  of 
its  progress.  And  W'e  may  here  remark  that  the  earlier  this  arrest- 
ment occurs,  the  distinction  of  the  true  sexual  type  of  the  malformed 
organs  will  always  be  the  less  marked,  because  the  younger  the 
embryo — and,  on  a similar  principle,  the  lower  we  descend  in  the 
scale  of  animal  existence — we  find  the  differences  between  tlie 
organs  of  the  two  sexes  proportionately  the  less  pj*onounced,  until 
at  last  we  arrive  at  that  primitive  type  in  which  these  organs  pre- 
sent altogether  a common,  neutral,  or  indeterminate  character. 

We  have  also  already  shown  that  at  a certain  early  stage  of  the 
development  of  the  female  organs,  the  female  clitoris  holds  the  same, 
or  nearly  the  same,  relatively  larger  size  to  the  whole  embryo  as  the 
penis  of  the  male,  and  that  so  far  we  may  consider  the  occasional 


EXCESSIVE  AND  RETARDED  DEVELOPMENT. 


497 


occurrence  of  spurious  hermaphroditism  from  magnitude  of  the 
clitoris,  and  its  resemblance  in  this  respect  to  the  male  organ,  as  a 
permanent  condition  of  a type  of  embryonic  structure  that  is 
normally  of  a temporary  or  transitory  existence  only.  But  besides 
this  permanence  of  the  embryonic  type  of  the  clitoris,  we  must 
further,  in  all  the  more  complete  instances  of  spurious  female 
hermaphroditism,  admit  an  excess  of  development  in  the  malformed 
external  sexual  parts,  and  more  particularly  in  the  line  of  the  median 
reunion  of  the  two  primitive  lateral  halves  or  divisions  of  these 
parts.  In  this  way  the  vulvar  orifice  of  the  vagina  (a  remnant  in 
the  female  of  the  primitive  perineal  cleft  or  fissure)  is  often  in  such 
cases  more  or  less  contracted  and  closed,  so  much  so  indeed  in  some 
instances  as  to  leave  only,  as  in  the  male,  a small  canal  common  to 
the  genital  and  urinary  passages.  If  the  median  junction  is  ex- 
tended still  farther,  this  canal  comes  also  to  imitate  the  male  urethra 
in  this  respect,  that  it  is  united  or  shut  up  heloiv  in  such  a way  as 
to  be  carried  onward  to  a greater  or  less  length,  and  in  a more  or 
less  perfect  condition  along  the  under  surface  of  the  enlarged  clitoris; 
and  occasionally,  as  in  some  of  the  cases  we  have  previously 
described,  the  male  type  of  structure  is  still  more  completely  repeated 
in  the  female  organisation  by  the  median  reunion  of  the  two  labia, 
giving  the  appearance  of  the  united  scrotum  and  closed  perineum  of 
the  opposite  sex, 

If  we  divide  the  whole  sexual  apparatus  of  the  male  and  female 
into  three  corresponding  transverse  spheres  or  segments — the  first 
or  deep  parts  including  the  testicles  and  ovaries ; the  second  or 
median  comprehending  the  male  seminal  canals  and  prostate  gland, 
and  the  female  oviducts  and  uterus ; and  the  third  or  external 
embracing  the  copulating  organs  of  the  two  sexes — we  shall  find 
that,  relatively  speaking,  the  deep  and  the  external  splieres  are 
naturally  most  developed  in  the  male  economy ; while  the  median, 
comprising  the  uterus  (the  principal  and  most  active  organ  in  the 
female  reproductive  system),  is  developed  in  the  greatest  degree  in 
that  sex.  In  malformed  females  presenting  a spurious  hermaphro- 
ditic character,  this  important  portion  of  the  female  sexual  organ- 
isation is,  in  general,  either  itself  in  some  respects  malformed,  or, 
from  the  structure  of  the  other  parts  of  the  sexual  apparatus  being 
imperfect,  its  specific  importance  in  the  economy  is  cancelled,  and 
therefore  the  energy  of  development  takes  the  same  direction  as  in 
the  male,  being  expended  upon  the  more  complete  evolution  of  the 
organs  of  the  external  and  deep  spheres.  Hence  the  greater  size  of 


498 


HERMAPHRODITISM. 


the  clitoris,  and  the  greater  development,  which  we  have  just  now 
pointed  out,  in  the  median  line  of  reunion  of  the  external  sexual 
parts ; and  hence  also  the  occasional  though  rare  occurrence,  in  the 
same  cases,  of  the  descent  of  the  ovaries  through  the  inguinal  rings 
into  the  labia — an  anomaly  that  certainly  consists  in  a true  excess 
of  development,  and  which  w’e  cannot  but  regard  as  interesting,  both 
in  this  respect,  and  as  affording  a new  point  of  analogy  between 
these  organs  themselves  and  the  male  testicles. 

There  is  another  and  equally  interesting  point  of  view  in  which 
we  may  look  upon  this  subject.  Not  only  are  the  forms  of  spurious 
hermaphroditism  which  we  have  been  considering  capable  of  being 
traced  backward  to  certain  transitory  types  of  sexual  structure  in 
the  embryos  of  those  animal  species  in  which  the  malformations  in 
question  occur,  but  they  may  be  shown  also  to  present  in  their  ab- 
normal states  repetitions  of  some  of  the  normal  and  permanent  condi- 
tions of  the  sexual  organs  in  various  species  of  animate  beings  placed 
lower  in  the  scale  of  life.  Thus  the  occasionally  imperforate  penis 
of  the  male  hermaphrodite  has  been  supposed  to  have  an  analogue  in 
the  naturally  solid  penis  of  the  species  of  some  of  the  genera  Doridium 
and  Hyalcea.^  Its  more  or  less  grooved  or  hypospadiac  condition  is 
similar  to  the  natural  type  of  the  same  part  in  some  hermaphrodite 
Mollusca,  as  in  the  Flanorhis  and  MurcxF  in  its  occasional  diminu- 
tive size  it  approaches  the  general  smallness  of  the  partially  fissured 
penis  of  most  birds  and  reptiles ; and  we  find  it  in  the  Eodentia 
and  Marsupiata  tied  down  by  a short  prepuce  in  a way  analogous 
to  Avhat  is  seen  in  some  cases  of  severe  hypospadias.  In  the  sloth 
{Bradn'pus  tnjdactylus)  the  penis  is  small  and  grooved  in  its  lower 
surface,  and  has  the  urethra  opening  at  its  base  and  in  several  of 
the  male  Eodentia  the  scrotum  is  also  cleft,  and  has  its  two  opposed 
surfaces  smooth,  humid,  and  free  from  hair,  as  in  most  cases  of 
hypospadiac  hermaphroditism  in  man.  In  Ophidian  and  in  most 
Saurian  Eeptiles,  the  male  seminal  ducts  open  at  once  externally,  as 
in  some  male  hermaphrodites,  at  the  root  of  the  fissured  penis. 

The  fact  of  the  testicles  sometimes  remaining,  in  cases  of  herma- 
phroditic formation  in  the  human  subject,  within  the  cavity  of  the 
abdomen,  presents  to  us  in  a permanent  state  their  original  but 
changeable  position  in  the  early  foetus,  and  at  the  same  time  affords 

^ Burdacli’s  Physiologic,  Bd.  i.  § 132,  p.  231. 

2 T\QiXQYa^m\s  Zeitschrift  fur  Physiologic,  Bd.  i.  s.  15  ; or  Cuvier,  Anat.  Comp 
tom.  V.  p.  182. 

3 Meckel,  Dcitrikjc  zur  verglcichendeii  Anatomic,  Bd.  ii.  cap.  i.  p.  125. 


LARGE  SIZE  OF  THE  CLITORIS  IN  ANIMALS. 


499 


a repetition  of  their  normal  situation  in  almost  all  the  lower  tribes 
of  animals,  and  in  the  Cetacea,  Amphibia,  Edentata,  and  some  Pachy- 
dermata,  as  the  Cape  Marmot  (Hyrax)  and  Elephant  among  the 
Mammalia. 

The  malformed  clitoris  in  instances  of  spurious  hermaphroditism 
assumes  also,  in  its  abnormal  state,  types  of  structure  that  we  find 
as  the  normal  condition  of  the  organ  in  various  inferior  animals. 
Thus  in  female  Cetacea  and  Rodentia,  and  in  the  animals  included 
in  Cuvier’s  order  of  Carnassiers,  but  more  particularly  among  the 
Quadrumana,  the  clitoris  retains  as  its  permanent  normal  type  that 
relatively  larger  size  which  we  observe  in  the  early  foetus,  and  in 
female  hermaphrodites,  in  the  human  subject;  and  further,  as  is 
sometimes  seen  in  such  malformed  individuals,  the  clitoris  becomes 
partially  traversed  by  the  urethra,  as  in  the  Ostrich,  Emu, ‘ and  Ant- 
eater  ; ^ and  in  the  Loris,  as  we  have  noticed  in  a preceding  page, 
and  Maki,  it  is  completely  enclosed,  like  that  of  the  male,  in  the 
body  of  the  organ,  forming  a continuous  and  perfect  canal  through  it. 

We  may  here  further  observe,  though  the  illustrations  should 
more  properly  belong  to  the  next  section,  that  in  cases  of  true  her- 
maphroditism also  in  man  and  quadrupeds,  as  well  as  in  the  above 
spurious  varieties,  there  may  often  be  traced  in  some  portions  of  the 
abnormal  structures  a sexual  type  bearing  a greater  or  less  analogy 
to  the  corresponding  parts  of  those  inferior  animals  that  are  natu- 
rally androgynous.  Thus,  in  instances  of  true  hermaphroditism,  the 
orifices  of  the  sexual  ducts  or  passages  occasionally  open  into  a 
common  cavity,  as  is  normally  the  case  in  some  species  of  Dorkliiim, 
Helix,  and  other  Mollusca : or  the  female  oviducts  or  Fallopian  tubes, 
and  the  male  vasa  deferentia,  run  closely  alongside  of  each  other 
without  any  communication  between  their  canals,  as  in  the  Alypsia 
and  most  Gasteropoda.  Indeed  the  occasional  co-existence  even  of 
both  testicles  and  ovaries  in  individuals  among  the  higher  animals 
would  be  only  a repetition  of,  or  retrogression  to,  the  normal  sexual 
type  of  those  genera  of  animals  that  we  have  just  named,  and  of  the 
Planaria,  Cestoidea,  and  other  natural  hermaphrodites. 

In  this  way  we  see  that,  as  in  many  other  monstrosities,  the 
several  varieties  of  malformation  in  the  sexual  organs  occurring  in 
spurious  human  hermaphroditism  do  not  consist  of  the  substitution 
of  an  entirely  new  and  anomalous  type  of  structure,  but  are  only 
repetitions  of  certain  types  of  the  same  organs  that  are  to  be  met 

^ Cuvier,  Anat.  Com}),  tom.  v.  p.  129. 

2 Meckel,  Archiv  fiir  die  Physiologic,  Bd.  v.  s.  66. 


500 


HERMAPHRODITISM. 


with  both  in  the  human  foetus  and  in  tlie  inferior  orders  of  animate 
beings.  The  investigation  of  the  whole  subject  shows  us,  in  reference 
to  the  sexual  organs,  what  is  equally  true  in  regard  to  all  the  other 
organs  of  the  body — that  their  different  stages  of  development  in 
the  embryos  of  man  and  of  the  higher  orders  of  animals  correspond 
to  different  stages  of  their  development  in  the  series  of  animate 
beings  taken  as  a whole ; so  that  here,  as  elsewhere,  the  facts  of 
Comparative  Anatomy  are  reproduced  in  those  of  Embryology,  and 
both  are  repeated  to  us  by  nature  on  a magnified  scale  in  the 
anatomy  of  the  malformations  of  the  part — a circumstance  amply 
testifying  to  the  intimate  relations  which  exist  between  Com- 
parative Anatomy,  the  anatomy  of  Embryonic  Development,  and 
that  of  Monstrosities.  Indeed,  proportionately  as  our  knowledge  of 
malformations  has  increased,  it  has  shown  us  only  the  more  strongly 
that  the  laws  of  formation  and  malformation — of  normal  and  ab- 
normal development — are  the  same,  or  at  least  that  they  differ  much 
more  in  degree  than  in  essence,  and  that  the  study  of  each  is  cal- 
culated reciprocally  to  illustrate  and  to  be  illustrated  by  the  study 
of  the  other. 


REMARKS  ON  THE  NATURE  OF  TRUE  HERMAPHRODITIC  lilALFORMA- 
TIONS,  UNITY  OF  SEXUAL  TYPE,  MALE  UTERUS,  ETC. 

Of  the  nature  and  origin  of  local  malformations  by  duplicity  we 
at  present  possess  much  less  precise  knowledge  than  of  those  of 
simple  defect  or  simple  excess  of  development ; but  there  are  certain 
facts  ascertained  with  regard  to  the  formation  of  the  internal  sexual 
organs,  which  may  enable  us  to  make  an  approach  at  least  to  accurate 
ideas  of  the  character  and  origin  of  those  abnormalities  that 
constitute  the  several  varieties  of  true  hermaphroditism.  These 
facts  relate  to  the  interesting  subject  of  the  unity  of  organisation, 
or  common  plan  of  structure,  which  is  manifested  in  the  correspond- 
ing male  and  female  reproductive  organs  of  the  human  subject,  and 
of  other  species  of  bisexual  animals.^ 

1 It  is  right  to  state  that  the  following  observations  on  the  pro-ovariuni, 
prostatic  vesicle,  etc.,  and  the  subsequent  deductions  from  them,  have  been  added 
during  the  revisal  of  this  essay  for  the  present  work — these  being  subjects  tliat 
have  only  come  to  be  discussed  since  the  essay  w’as  originally  published  in  1839. 
Three  preceding  cases — those  of  Vrolik,  Blackman,  and  Banon — have  also  been 
added,  with  references  in  the  notes  to  some  others,  recorded,  like  them,  during  the 
last  ten  or  fifteen  years.  In  other  respects  the  essay  stands,  almost  entirely,  as  it 
was  originally  printed  in  the  Cycloixcdia  of  Anatomy.  [Ed.  of  Obstetric  Memoirs.^ 


UNITY  OF  SEXUAL  ORGANISATION. 


501 


By  several  of  the  Greek,  Eoman,  and  Arabian  physiologists^  the 
respective  organisations  of  the  two  sexes  were  considered  as  in  some 
degree  typical  of  one  another,  the  female  being  regarded  as  an  in- 
verted male,  with  the  testicles  and  penis  turned  inwards  to  form  the 
ovaries  and  uterus.  This  doctrine  of  analogy  between  the  male  and 
female  sexual  organs  has,  with  various  modifications,  been  very 
generally  admitted  by  modern  physiologists,  and  in  some  of  its 
bearings  it  has  been  made,  more  particularly  of  late  years,  the 
subject  of  considerable  discussion.  The  testicles,  or,  more  correctly 
speaking,  the  bodies  of  the  testicles,  are  still  regarded  as  organs 
which  correspond  with  the  ovaries  in  their  original  situation,  in 
their  vascular  and  nervous  connections,  and  in  their  relative  sexual 
functions.  The  recent  progress  of  the  anatomy  of  the  development 
of  the  embryo  has  also  shown  that  the  two  organs  correspond 
in  their  primitive  origin.  It  is  now  well  ascertained  that  the 
large  masses  occupying  each  side  of  the  abdomen  of  the  embryo  at 
an  early  stage  of  development,  and  which  Eathke  has  named  the 
Wolffian  bodies,  after  their  illustrious  discoverer,  form,  in  Birds  and 
Mammalia  at  least,  the  primordial  matrices  upon  which  the  urinary 
and  genital  organs  are  developed.  On  the  inner  side  of  each  of 
these  matrices  a small  body  is  early  developed,  which  seems  to 
become  afterwards  either  a testicle  or  an  ovary,  according  to  the 
particular  ulterior  sexual  type  which  the  embryo  assumes.  According 
to  the  testimony  of  Valentin,  no  difference  in  appearance  or  structure 
can  be  detected  at  their  earlier  periods  of  formation  and  development, 
between  the  testes  and  ovaries.^ 

If  this  were  a fit  opportunity  for  discussing,  in  all  its  details, 
the  unity  of  type  between  the  male  and  female  reproductive  organs, 
it  would  be  easy  to  prove  further  the  justness  of  tliose  greater 
analogies  that  we  have  mentioned  between  the  ovaries  and  the 
proper  bodies  of  the  testes,  by  pointing  out  other  numerous  minor, 
but  still  strong,  points  of  correspondence  manifested  in  the  abnormal 
conditions  and  localities  of  these  two  representative  organs  in  the 
higher  animals,  and  in  their  conformity  of  structure  in  some  of  the 
lower.  Thus  among  insects,  in  the  genus  Lihellula,  the  long 
cylindrical  testes  of  the  males  correspond  with  the  long-shaped 
ovaries  of  the  females ; in  the  Lociista  and  Gryllotalpa,  there  are 
ramose  bunched  testicles  with  antilogous  fasciculated  ovaries  ; in  the 

^ Aristotle,  Hist.  An.  lib.  i.  17  ; Galen,  De  Scminc,  lib.  ii.,  and  De  TJsii 
Partium,  c.  i,  ; Eliases,  Dc  PiC  Mcdicd,  lib.  i.  cap.  26  ; Avicenna,  De  Mcmhris 
Gcncrat.  lib.  iii.  21,  etc.  - Enf.wickclun(js(jcschichte,  p.  391. 


502 


HERMAPHRODITISM. 


Lamellicornia  we  find  compound  radiating  and  united  testes,  with 
similar  radiating  and  united  ovaries ; and  sometimes,  as  in  the 
genera  Melolontha  and  Trichiiis,  the  number  of  the  single  bodies  in 
the  testicles  corresponds  with  the  number  of  the  oviducts.^ 

Organ  of  Bosenmuller  ; Fro-ovarium  of  Kobelt ; Canals  of  Gaertner, 
etc. — In  further  following  out  the  unity  of  type  between  the  genital 
organs  of  the  two  sexes,  the  epididymis  of  the  male  has  usually  been 
compared  to  the  infundibula  or  fimbriated  extremities  of  the 
Fallopian  tubes  of  the  female,  and  the  seminal  ducts,  or  vasa 
deferentia  of  the  Fallopian  tubes  themselves.  This  view,  however, 
has  been  considerably  changed  in  some  important  respects,  by  the 
later  investigations  of  embryologists  and  anatomists,  and  particularly 
by  the  observations  of  Kobelt  and  others,  upon  the  transformations 
and  relations  of  the  two  Wolffian  bodies  and  their  ducts.  We  have 
already  alluded,  in  the  preceding  paragraph,  to  the  Corpora 
Wolfiiana  as  two  large  abdominal  bodies  in  the  early  embryo,  on  the 
inner  side  o‘f  which  the  glandular  organs  constituting  the  future 
testes  or  ovaries  are  first  observed  in  the  study  of  development. 
These  Corpora  Wolfiiana  are  very  large  in  the  embryo  of  some  of 
the  lower  animals,  as  in  reptiles  and  birds.  In  the  early  Mammalian 
embryo,  the  two  Wolffian  bodies  are  oblong  masses,  placed  one  on 
each  side  of  the  spine,  and  stretching  from  the  vicinity  of  the  heart 
to  the  lower  end  of  the  abdomen.  They  send  off  two  excretory 
tubes,  the  Wolffian  ducts,  which  open  below  into  the  cloaca,  or 
latterly  into  that  division  of  the  cloaca  which  form.s  the  uro-genital 
sinus  or  common  genito-urinary  canal.  Each  Wolffian  body  consists, 
when  fully  developed,  of  a congeries  of  transverse  coecal  tubes,  all  of 
them  opening  into  the  common  excretory  or  efferent  duct,  Avhich 
passes  along  the  outer  side  of  the  organ.  Most  anatomists  have 
described  the  Wolffian  bodies  as  temporary  embryonic  glands,  and 
altogether  transitory  structures  only.  “ In  both  sexes,”  according  to 
the  statement  of  Muller  in  1840,  “ the  Wolffian  bodies  entirely  dis- 
appear, and  are  not  converted  into  any  other  organ.”’ — The 
investigations,  however,  of  Kobelt^  have  latterly  proved  that  this 
view  was  erroneous,  and  that  we  can  still  trace  remains  of  the 
Wolffian  bodies  in  the  adult  human  female,  and  often,  also,  in  the 
adult  male. 

1 s Entomology,  § 154,  p.  222. 

2 Muller’s  Elements  of  Physiology,  by  Dr.  Baly,  p.  1637.  The  same  opiuiou 
is  expressed  by  M.  Coste  in  the  Comptes  Pendus  for  1839,  p.  331. 

2 Per  Nehen-Eier stock  des  Weihes,  etc.,  Heidelberg,  1847. 


COUPORA  WOLFFIANA. 


503 


Professor  Eosenmiiller  of  Leipsic  published,  in  1802,  a remark' 
able  essay,*  in  which  he  pointed  out  the  existence  in  the  human 
female  foetus  and  infant  of  a peculiar  fan-like  structure,  formed 
of  diverging  ducts,  and  lying  in  the  duplicature  of  peritoneum  con- 
necting the  ovary  to  the  outer  or  fimbriated  portion  of  the  Fallopian 
tube.  He  did  not  appear  to  have  searched  for  this  canaliculated 
“ Corpus  Conicum,”  as  he  terms  it,  in  any  subjects  older  than  two 
years  of  age.^  Kobelt  has  demonstrated,  however,  that  this  body  or 
organ  of  Rosenmuller  exists  in  the  same  locaftty  in  adult  females-— 
namely,  between  tlie  Fallopian  tube  and  ovary,  inclosed  between  the 
serous  coats  or  folds  of  the  AIjb  Yespertilionis and  he  has  given 
to  it  the  name  of  “ Pro-ovarium.”  He  has  shown  also,  by  the  evi- 
dence of  the  history  of  this  organ  or  structure,  from  embryonic  to 
adult  life,  and  by  its  position  and  anatomical  characters,  that  it  con- 
sists in  reality  of  the  remains  of  that  Wolffian  body  which  is  so 
very  large,  and  apparently  so  very  important  a structure,  in  early 
embryonic  life.  Rosenmuller  hints  that  the  ‘’corpus  conicum  ejus- 
dem  ductus,”  * which  he  discovered  in  the  female  foetus,  may  have 
an  analogy  to  the  epididymis  and  vas  deferens  of  the  male ; and 
Kobelt  has  tried  to  prove  that  in  man,  the  Wolffian  body  so  far 
remains,  that  it  has  gone  to  constitute,  in  great  part,  the  epidid3’mis  ; 
the  cul-de-sacs  or  blind  tubes  of  the  former  being  transformed  into 
the  coni  vasculosi  of  the  latter  body,  and  the  inferior  coeca  of  the 
Corpus  Wolffianum  being  converted  into  the  so-called  vasa  aberrantia 
of  Haller.  In  both  the  adult  female  and  male  some  of  the  higher 
tubes  or  coeca  of  the  Wolffian  bodies  often  remain,  and  become  ex- 
panded into  those  cysts  which  form  the  sessile  and  pediculated 
hydatoid  bodies  that  are  so  very  frequently,  or  indeed  constantly, 
found  in  the  upper  part  of  the  broad  ligament,  and  on  the  fimbriate 
edges  of  the  Fallopian  tubes,  and  also  on  and  beneath  the  surface  of 
the  male  epididymis.® 

^ Quaedam  de  Ovariis  Emhryonum  et  Foetuuyn  Hiimanorv.m.  An  excellent 
plate  illustrates  the  essay.  Jle  thinks  Roederer  and  Trew  were  probably 
acquainted  with  the  structure  which  he  describes,  p.  8. 

2 At  p.  14,  loc.  cit.,  he  tells  us  he  found  this  special  structure  in  an  infant  who 
died  when  twelve  days  old,  “admodum  magnum,  constare  e multis  canaliculis  in 
basi  corporis  conoidci,  inter  se  convolutis  et  latioribus.”  In  this  specimen  he 
reckoned  the  canals,  or  canalieuli,  as  amounting  to  about  twenty  in  number. 

^ See  also  the  excellent  diagram  of  its  structure  and  position  in  H.  Meckel’s 
Morphologic  der  Gcschlechtszcuge^  1848.  Tab.  ii.  fig.  21,  etc. 

^ Quaedam  dc  Ovariis,  etc.,  p.  15. 

® Rosenmuller  delineates  (pi.  i.  figs.  G and  7),  a hydatoid  body  or  “corpus- 
culum  sacciforme,”  attached  to  the  edge  of  the  broad  ligament,  and  connecteil 
88 


504 


HERMAPHRODITISM. 


According,  then,  to  this  modern  view  of  the  subject,  we  ought, 
in  reference  to  the  doctrine  of  the  unity  of  structure  between  the 
two  sexes,  to  regard  the  epididymis  of  the  male  as  having  its  true 
analogue  in  the  pro-ovarium  of  the  female,  and  not  in  the  fimbriated 
extremity  or  infundibulum  of  the  Fallopian  tube. 

The  female  Fallopian  tubes  and  male  vasa  deferentiawere  formerly, 
as  has  been  already  stated,  very  generally  considered  as  typical  or 
analogous  structures  -in  the  two  sexes.  Miiller,^  however,  and 
Rathke  ^ first  pointed  out  that  in  birds  and  reptiles  these  two  sets 
of  tubes  were  developed  separately  and  distinctly  from  each  other 
in  the  early  embryo.  Bergmann,®  Leuckhart,^  and  more  especially 
Kobelt,®  have  latterly  shown  that  the  same  fact  is  true  with 
regard  to  the  early  history  of  deyelopment  of  these  parts  in  the 
mammalian  embiyo  and  in  the  human  subject.  Vrolik®  and 
Valentin 7 have  published  the  same  morphological  views;  and  I 
know  that  their  correctness  is  maintained  by  Professor  Allen 
Thomson,  undoubtedly  the  greatest  authority  on  such  a question  in 
this  country.  From  the  researches  of  these  and  other  observers,  it 
seems  now  fully  proved  that  in  the  early  human  and  mammalian 
embryo,  in  both  sexes,  two  hollow  filaments  or  tubes  on  each  side 
pass  from  the  region  of  the  testes  or  ovaries  above  to  the  uro-genital 
sinus  or  canal  below.  These  two  sets  of  tubes  form  at  that  period 
the  organic  link  or  connection  between  what  latterly  become  the 
true  reproductive  glands,  namely,  the  ovaries  or  testicles  and  the 
external  organs  of  copulation.  One  of  these  pairs  of  tubes  on  each 
side  consists  of  the  excretory  duct  of  the  Wolfhan  body,  and  this 
pair  in  the  course  of  development  becomes  transformed  in  the  male 

witli  the  body  he  has  described.  Folliii  and  Verneuil  have  latterly  called  the 
special  attention  of  the  profession  in  France  to  the  cysts  formed  out  of  the  per- 
sistent tubes  of  the  Wolffian  bodies.  See  Follin’s  Rcchcrches  sur  le  Cordis  de 
Wolff,  published  as  a Thesis  in  1851  ; and  Verneuil’s  Bccherches  sur  les  Kystesdc 
VOrgane  de  Wolff  dans  les  deux  Sexes,  in  the  Memoires  de  la  Societe  de  Chirurgic, 
tom.  iv.  p.  58. 

^ Bildwngsgeschichte  der  Genitalieu,  1830.  Elements  of  Physiology,  vol.  ii.  p, 
1637.  Muller  still  continued  to  hold,  however,  that  in  Mammalia,  both  the  Fal- 
lopian tube  in  the  female,  and  the  vas  deferens  in  the  male,  were  on  each  side 
formed  out  of  a single  distinct  structure,  having  originally  the  appearance  of  a 
filament  running  along  the  outer  border  of  the  Wolffian  body. 

2 EntwickelungsgescMchte  der  Natter,  1839,  p.  212. 

^ See  AVagner’s  Handworterhiich,  etc, 

^ Zar  Anatomie  und  Physiologie  dcs  Geschlechtsorgane,  1847,  p.  90. 

® Der  Nchen-Eier stock  des  Weibes,  etc.,  1847. 

Tabulae  ad.  Illustrandum  Embryogenesin  Honiinis,  etc,.  Tub.  xcv. 

^ Text-Book  of  Physiology,  661. 


PRO-OVAHIUM. 


505 


foetus  into  the  two  male  vasa  deferentia.  Of  these  Wolffian  ducts 
or  ultimate  vasa  deferentia,  the  upper  portion  on  each  side  is  ulti- 
mately united  in  the  male  subject  to  the  secreting  structure  of  the 
testicles  by  tubes  that  are  in  part  the  remains  of  the  Wolffian  body 
itself,  and  which  form  the  epididymis.  On  the  other  hand,  in  the 
female  embryos  of  most  Mammalia,  these  Wolffian  ducts  entirely 
disappear,  or,  as  in  female  liuminantia  and  Pachydermata,  they 
remain  as  rudimentary  or  imperfect  ducts,  lying  between  the  layers 
of  the  ligamenta  lata,  and  leading  from  the  organ  of  Eosenmuller, 
or  persistent  Wolffian  body,  down  to  the  sides  of  the  uterus  anid 
vagina,  and  open  into  the  latter,  forming,  in  fact,  the  canals  of 
Gaertner  in  the  cow,  sow,  etc.  The  other  pair  of  tubes — the  cords 
of  Muller,  seen  in  the  early  embryo  of  both  sexes  running  by  the 
sides  of  those  already  mentioned,  undergo  two  very  different  trans- 
formations in  the  male  and  female.  In  the  female,  they  remain 
open  at  their  upper  extremity  and  detached,  and  come  to  constitute 
the  canals  of  the  Fallopian  tubes  and  their  infundibula  or  fimbriated 
extremities.  On  the  contrary,  in  the  embryo  of  the  male  human 
subject,  and  of  most  other  Mammalia,  they  early  disappear,  particu- 
larly in  their  upper  portion.  In  the  male  beaver,  rabbit,  goat,  etc., 
they  remain  as  rudimentary  extensions  of  the  horns  of  the  organ  we 
shall  presently  describe — namely,  the  male  utriculus  bicornis  of  these 
animals.  Their  lower  portions  may  be  considered  as  forming,  or 
being  transformed  by  their  coalescence  into,  the  male  utriculus  itself, 
in  those  species  of  animals,  as  in  man,  where  this  male  utriculus 
or  prostatic  vesicle  is  single  in  form,  and  median  in  position. 

Male  Utriculus;  Uterus  Mascidinus. — Formerly  great  diversity  of 
opinion  prevailed  as  to  the  morphological  prototype  or  analogue  of 
the  female  uterus  in  the  male  genital  system.  Some  anatomists,  as 
Burdach,  Steghlener,  and  Blainville,  regarded  the  uterus  and  male 
vesiculse  seminales  as  corresponding  parts ; while  others,  as  ]\Ieckel, 
Cams,  Schmidt,  Ackermann,  and  Seres,  compared  the  uterus  to  the 
male  prostate.  Instances  of  malformation  on  record  appeared  to 
favour  both  opinions,  and  there  were  other  cases  Avhich  almost 
inclined  anatomists  to  believe  that  the  vesiculae  seminales  corre- 
sponded to  the  fundus  or  body  of  the  uterus  in  the  human  subject, 
and  to  the  cornua  uteri  in  quadrupeds  ; while , the  prostate  repre- 
sented in  the  male  structure  the  lower  portion  or  cervix  of  the  same 
organ. 

M.  Geoffroy  St.  Hilaire  divided  the  uterus  of  the  human  subject 
into  the  body,  and  the  upper  part  or  fundus,  the  latter  correspond- 


506 


HERMAPHRODITISM. 


ing  to  what  constitutes  the  cornua  uteri  in  the  human  embryo,  and 
in  adult  quadrupeds.  Further,  believing  that  in  the  determination 
of  all  analogies  in  type  and  structure  between  different  organs,  the 
origin  and  course  of  the  blood-vessels  supplying  the  part  ought  to 
be  our  principal  criterion,  he  was  led  by  the  study  of  the  distribu- 
tion of  the  branches  of  the  hypogastric  arteries  to  consider  the  body 
of  the  uterus  and  the  vesiculae  seminales  as  repetitions  of  each  other 
in  the  two  sexes ; and,  contrary  to  the  opinion  of  most  anatomists, 
he  conceived  that  the  male  vasa  deferentia  strictly  correspond  with 
the  fundus  or  cornua  uteri,  and  that  the  epididymis  represents  a 
coiled-up  Fallopian  tube,  or,  in  other  words,  that  the  Fallopian  tube 
is  an  unrolled  epididymis.^ 

The  later  investigations,  however,  of  Professor  AVeber  of  Leipsic,* 
and  others,  have  thrown  a new  and  most  important  light  upon  this 
question  in  morphological  anatomy,  by  demonstrating  that  in  man 
and  in  other  males  there  exists,  distinct  both  from  the  vesiculse 
seminales  and  prostatic  gland,  a small  rudimentary  uterus — a true 
representative,  in  the  unity  of  organisation  between  the  two  sexes, 
of  the  more  highly  developed  uterus  of  the  female  subject. 

Early  in  the  last  century,  Morgagni  described  in  the  region  of 
the  caput  gallinaginis  in  the  male  urethra  a small  sac  or  cell.  He 
named  it  the  Sinus  Pocularis,^  and  has  given  two  excellent  and 
illustrative  drawings  of  its  situation,  orifice,  and  cavity.  He  found 
this  cell  or  vesicle  in  fourteen  out  of  fifteen  human  subjects  that  he 
dissected.  Of  late  years,  since  the  attention  of  anatomists  has  been 
specially  recalled  to  this  part  by  Weber,  Huschke,  Leuckhart,  and 
others,  it  has  received  a variety  of  appellations,  as  that  of  prostatic 
vesicle,  prostatic  utricle,  uterus  umsculinus,  etc. 

In  man  this  utricular  body  is  a small  oblong  cul-de-sac,  or  hol- 
low, flask-shaped  vesicle,  situated  in  the  space  or  angle  between  th^^ 
lower  ends  of  the  ejaculatory  ducts,  and  opening  below  by  a narrow 
neck  and  orifice  upon  the  posterior  wall  of  the  urethra,  at  the 
anterior  edge  of  the  caput  gallinaginis  or  verumontanum.  In  man 
its  fundus  is  imbedded  between  the  lobes  of  the  prostate  gland,  but 
the  lower  portion  of  it,  projecting  as  a narrow  ridge  on  the  middle 
and  lower  surface  of  the  prostatic  portion  of  the  urethra,  constitutes 

^ Phil.  Anat.  1822,' tom.  i.  p.  471. 

2 Zusdtzc  zur  Lehre.  vom  Bane  und  den  Verrichtungen  der  Gcschlcchtsorgane, 
Leipsic,  1846. 

^ Adeersaria  Anatomica,  iv.  1723,  p.  6,  tab.  figs.  1,  2.  It  was  previously 
figured  by  Albinus  in  las  Annotat.  Academ.  iv.  tab.  iii.  fig.  3 ; and  by  Cowper, 
in  his  work  entitled  Glandularurn  nuper  detect.  Descriptio,  i.  3. 


UTERUS  MASCULINUS. 


507 


the  biilk  of  the  caput  gallinaginis.  The  normal  site  of  its  opening 
into  the  urethra  is,  in  the  human  subject  and  in  most  Mammalia,  at 
a point  intermediate  between  the  two  orifices  of  the  seminal  or 
ejaculatory  ducts.  ’ Sometimes,  though  rarely,  as  in  two  of  Mor- 
gagni’s human  subjects,  it  opens  into  one  of  the  ejaculatory  tubes 
themselves  ; and  this,  indeed,  appears  to  be  its  normal  structure  in 
some  animals,  as  in  the  hare.  In  man,  the  length  of  the  cavity  of 
the  prostatic  vesicle  varies  from  three  to  six  lines ; at  its  upper 
extremity  its  breadth  is  generally  two  lines  ; but  it  sometimes 
attains  a larger  size.  The  lining  membrane  of  its  cavity  is  covered 
with  small  mucous  glands,  packed  closely  together.  This  male 
utriculus  or  prostatic  vesicle  is  of  much  larger  size,  and  in  a state  of 
greater  development,  in  the  males  of  some  of  the  lower  Mammalia  ; 
and  it  was  principally  from  studying  its  various  forms  and  relations 
in  these  animals  that  Weber  discovered  the  true  morphological 
character  of  the  prostatic  vesicle,  and  its  typical  analogy  with  the 
female  uterus. 

In  the  embryos  of  the  sheep  and  sow,  at  a certain  period  of 
development,  the  uterus  or  prostatic  vesicle  of  the  male  is  so  very 
like  the  uterus  of  the  female,  that,  according  to  Rathke,^  the  two 
organs  cannot  be  distinguished  from  each  other.  In  the  adults  of 
some  male  animals  this  utriculus,  or  male  uterus,  is  an  organ  of  con- 
siderable size,  and  presents  much  of  the  form  and  relations  of  the 
female  uterus  in  the  same  species.  For  instance,  in  the  rabbit  it  is 
an  organ  from  one  to  one  and  a half  inches  in  length,  projecting 
behind,  between  the  rectum  and  urinary  bladder,  and  with  its 
fundus  divided  and  stretched  out  laterally  into  two  short  cornua, 
like  those  of  the  female  uterus.  The  long  uterus  masculinus  of  the 
male  beaver  is  single  at  the  cervix,  and  split  or  divided  above  into 
two  horns,  like  the  female  uterus  in  the  same  species  ; and,  like  it, 
too,  the  male  organ  is  provided  with  ligamenta  lata,  etc.  In  the 
goat  its  cornua  often  stretch  to  the  testicles.  In  some  adult  animals 
the  male  uterus,  however,  is  even  less  developed  than  it  is  in  the 
human  subject ; and  it  seems  to  vary  greatly  even  in  different  in- 
dividuals of  the  same  species. 

Few,  or  indeed  none,  of  the  eminent  anatomists  who  have  in 
later  years  studied  the  subject  of  the  prostatic  vesicle  or  utricle,  as 
Huschke,  Leydig,  Rathke,  Leuckhart,  Bischoff,  Arnold,  Wahlgrew, 
Kolliker,  Duvernoy,  Goodsir,  and  Allen  Thomson,  have  at  all 

- Weber’s  Zusdtze,  etc.,  p.  65.  See  his  comparative  sketches  of  the  male  and 
female  uterus,  in  these  animals,  pi.  v.  fig.  4. 


508 


HERMAPHRODITISM. 


doubted  that  this  organ  is  a representative  or  analogue  in  the  male 
organisation  of  the  genital  canals  of  the  female.*  But  different 
opinions  have  been  expressed  as  to  whether  it  morphologically 
represents  the  vagina,  or  the  uterus,  or  both.  H.  Meckel  ^ at  one 
time,  and  in  opposition  to  almost  all  other  authorities,  suggested 
and  maintained  that  it  was  the  analogue  of  the  vagina  rather  than 
of  the  uterus ; Weber  considered  it  as  the  male  prototype  of  the 
female  uterus ; and  still  more  lately,  Bimbaum  ® and  Leuckhart  * 
have  shown  that  this  organ  may  be  more  truly  held  as  the  morpho- 
logical equivalent  of  the  whole  sinus  genitalis,  both  the  uterus  and 
the  vagina — an  opinion  now  generally  shared  in  by  those  who 
formerly  took  a different  view  of  the  subject.  Huschke  has  some- 
times found  the  lower  or  vaginal  portion  of  the  male  utriculus  sepa- 
rated from  the  upper  and  dilated  end  by  a constricted  point,  as  if 
indicating  its  division  normally  into  uterus  and  vagina.®  Indeed,  it 
IS  only  in  accordance  with  this  last  doctrine  that  we  can  understand 
the  relative  positions,  and  modes  of  junction,  of  the  genital  and 
urinary  canals  in  some  monstrosities,  and  the  fact  of  the  great 
variety  of  forms  and  shapes  which  the  male  uterus  or  prostatic 
vesicle  assumes,  when  it  is  found — as  so  often  happens — preter- 
naturally  enlarged  and  disproportionately  developed  in  different 
kinds  of  hypospadiac  and  hermaphroditic  malformation. 

The  only  remaining  internal  organs  of  generation  requiring  con- 
sideration under  the  present  head  are  the  prostate  gland  and  vesiculse 
seminales  of  the  male.  Formerly,  as  we  have  already  seen,  these 
male  structures  were,  in  different  points  of  view,  usually  looked  upon 
as  prototypes  of  the  female  uterus,  or  the  two  were  held  as  analogues, 
one  of  the  neck,  and  the  other  of  the  body  and  fundus,  or  cornua,  of 
that  important  organ  in  the  female  economy.  The  discovery  of  the' 
existence  of  a true  uterus  masculinus,  find  the  investigation  of  its 
morphological  import  and  relations,  have  entirely  dispelled  these 
vi§ws.  At  present,  the  typical  analogues  in  the  female,  of  the 
prostate  gland  and  vesiculse  seminales  in  the  male,  are,  in  conse- 
quence, by  no  means  fixed  and  established,  and  some  authorities  are 

^ Some  of  the  various  diseased  states  attributed  to  enlargement,  etc.,  of  the 
third  lobe  of  the  prostate  gland  Avill  yet  be  found,  I believe,  to  be  morbid  states 
of  this  prostatic  vesicle.  To  the  minds  of  some,  the  investigation  of  “ the  diseases 
of  the  Male  Uterus  ” would  appear  to  be  almost  a paradox  in  thought  and  words. 

2 Ziir  Morphologic  dcr  Geschlechtswerkzcugc,  p.  47. 

^ Bcschrc.ihung  eincr  Bildungshcmming,  p.  15. 

Cyclopaedia  of  Anatomy  and  Physiology,  vol.  iv.  p.  1427. 

® Soemmering’s  Lchrc  voii  den  Eingeweiden,  p.  409. 


TKOSTATE  GLAND  AND  VESICUL^.  SEMINALES. 


509 


inclined  to  look  upon  these  male  organs  as  peculiarly  and  entirely 
male  structures,  that  have  not  any  true  morphological  equivalents 
representing  them  in  the  construction  of  the  female.  In  their 
original  embryonic  origin,  as  well  as  in  their  ultimate  adult  relations, 
the  vesiculce  seminales  seem  to  be  parts  and  appendages  of  the  male 
vasa  deferentia ; and  perhaps,  morphologically,  they  ought  to  be  con- 
sidered merely  as  highly  and  peculiarly  developed  portions  of  the 
lower  end  of  the  male  seminal  tubes,  and  consequently  of  the 
analogous  ducts  of  Wolff  and  Gaertner.  The  scattered  and  imper- 
fect form  which  they  present  in  some  hermaphroditic  malformations, 
as  in  the  cases  described  by  Ackermann  and  Steghlener,^  seems  to 
accord  with  this  view.  The  vesiculse  seminales  distinctly  and  essen- 
tially belong  to  the  sexual  canals  and  structures ; but  the  prostate 
gland  seems  more  truly  an  appendage  to  the  urinary  tubes  and 
urinary  organisation.  Generally,  its  excretory  ducts  open,  and  its 
secretions  are  discharged,  into  the  urethral  canal  somewhat  before 
the  male  seminal  tubes  enter  into,  or  join  with,  that  canal.  And  if 
we  are  to  find  a true  prototype  in  the  female  of  the  prostate  gland 
of  the  male,  we  shall  probably  detect  it  in  the  follicular  glands  and 
structures  that  exist  so  abundantly  in  the  course,  and  at  the  ex- 
tremity, of  the  female  urethra — a canal  which,  throughout  its  length, 
is  truly  an  analogue  of  the  posterior  prostatic  and  membranous  por- 
tion only  of  the  male  urethra. 

In  the  observations  made  under  the  present  head  I have  spoken 
only  of  the  analogous  organs  traceable  in  the  internal  sexual  organi- 
sation of  the  male  and  female.  Already,  in  preceding  sections,  the 
analogous  organs  and  structures  observed  in  the  external  genital 
construction  of  the  two  sexes  has  been  discussed.  If  we  now- 
attempt  to  show,  in  an  abridged  and  tabular  form,  the  unity  or 
common  plan  of  structure  between  the  different  parts  and  organs 
belonging  to  the  whole  sexual  organisation  of  the  male  and  female 
— the  morphological  prototypes  or  equivalents  in  each  majq  with 
the  explanations  and  reservations  previously  stated,  be  briefly  repre- 
sented as  follows : — 


In  the  Male. 


In  the  Female. 


Epididymes 

Vasa  deferentia  and  tlieir  vesicular 


Bodies  of  Testes 


Ovaries. 

f Pro-ovaria  and  bodies  of  WolfT  and  • 
( Rosen  muller. 

i Ducts  of  Wolffian  bodies  or  canals  of 


dilations 


Gaertner. 


’ See  previously  these  cases  at  p.  465. 


510 


HERMAPHRODITISM. 


In  the  Male. 

Cornua  of  male  utriculus 

Male  or  prostatic  utriculus 

Gubernaculum  testis 

Tunica  vaginalis 

Cowper’s  glands  and  their  ducts  open- 
ing into  bulb  of  urethra 

Urethra  behind  bulb  and  prostate 
gland 

Bulb  of  urethra 

Penis,  and  its  corpora  cavernosa,  liga- 
ments, etc. 

Prepuce  and  integumental  covering  of 
penis 

Gians  penis  and  corpus  spongiosum 

Sides  of  scrotum 

Perineal  closure  of  genital  sinus 


In  the  Female.. 

I Fallopian  tubes  and  their  infundi- 
( hula. 

Female  uterus  and  vagina. 

Round  ligament. 

Process  of  Nnck. 

Glands  of  Bartholin,  and  their  ducts 
opening  at  the  roots  of  nympha?. 
j Whole  urethra  and  its  follicular 
I glands. 

Vulva  or  vulvar  end  of  vagina. 

{ Clitoris,  and  its  corpora  cavernosa, 
\ ligaments,  etc. 

j Prreputium  clitoridis,  and  nymphfe 
( or  labia  minora, 
i Vascular  nodule  of  clitoris  and  the 
( erectile  bulbi  vestibuli. 

Labia  majora. 

Hymen. 


In  relation  to  these  equivalent  or  analogous  parts  in  the  two 
sexes,  as  given  in  the  preceding  table,  it  is  scarcely  necessary  to 
observe  that  some  of  them — as  the  cornua  of  the  male  utricle  on  the 
male  side,  and  the  ducts  of  Wolff,  or  Gaertner,  on  the  female  side — 
are  structures  pertaining  to  the  embryonic  condition  only,  and  not 
normally  persistent  or  traceable  in  the  organisation  of  the  extra- 
uterine  being ; though  their  morphological  prototypes  are  fully 
developed  in  the  adults  of  the  opposite  sex.  Further,  I would  here 
beg  to  add  the  following,  as  a general  remark  or  law  which  seems 
to  me  to  explain  many  of  the  hermaphroditic  anomalies  and  sexual 
combinations  of  structure  that  we  meet  with,  that  whenever  we  find 
the  development  of  the  sexual  organs  of  an  individual,  whether  male 
or  female,  restrained  or  arrested,  so  as  to  be  heloiv  the  normal  type 
or  standard,  some  of  the  analogous  or  prototypic  organs  of  the 
opposite  sex  will  in  this  same  individual  be  observed  to  be 
developed  in  excess,  or  above  their  normal  type  or  standard.’ 

Some  other  organs,  besides  those  we  have  referred  to,  and  that 
are,  so  far  as  regards  their  functions,  peculiar  and  essential  to  one 
sex  only,  are  nevertheless  found  to  be  repeated  in  the  opposite  sex 
in  the  form  of  an  analogous  rudimentary  type  of  structure.  Thus, 
in  the  male,  we  may  observe  the  unity  of  sexual  structure  maintained 
in  the  presence  of  the  rudiments  of  the  mammary  gland,  Avhich  is 
functionally  an  organ  of  the  female  system  only.  In  the  human 
subject,  and  in  animals  whose  females  have  pectoral  mammae,  these 
organs  occupy  the  Siime  position  in  the  male  ; while  in  those  species 


ANALOGY  OF  MALE  AND  FEMALE  ORGANS. 


511 


of  quadrupeds  in  which  they  are  placed  in  the  inguinal  region,  we 
find  them  in  the  corresponding  males  forming  the  scrotum  or  bags 
for  containing  the  testicles.  Hence,  as  we  have  already  seen,  the 
testicles,  in  cases  of  malformation  in  these  animals,  are  often  laid 
upon  or  imbedded  in  the  udder.  In  the  same  way  in  the  Mar- 
supiata,  the  bone  which  the  female  has  for  supporting  the  marsupium 
is  repeated  in  the  organisation  of  the  male,  although  in  the  latter 
we  cannot  conceive  it  to  serve  any  possible  use.^ 

In  the  female  also  we  observe  in  some  points  a similar  disposi- 
tion to  the  rudimentary  repetition  of  parts  that  are  essential  or 
peculiar  only  to  the  male  organisation,  as  in  the  repetition  in  the 
clitoris  of  some  female  Rodentia  of  the  penis-bone  of  the  male,^ 
and  in  the  formation  of  rudimentary  forms  of  those  processes  of 
peritoneum  which  constitute  the  tunicse  vaginales.  We  are  our- 
selves inclined  also  to  regard,  as  was  seen  in  the  preceding  table, 
the  common  crescentic  form  of  the  hymen  of  the  human  female  in 
the  same  light, ^ and  to  consider  it  merely  as  an  abortive  attempt  at 
that  closure  of  the  sinus  genitalis  or  perineal  fissure  which  we  have 
already  described  as  effected  at  an  early  period  in  the  male  embryo 
— an  opinion  in  which  we  conceive  Ave  are  borne  out  both  by  the 
history  of  the  development,  and  the  study  of  the  malformations,  of 
the  external  sexual  parts  in  the  female. 

M.  Isidore  St.  Hilaire  read,  in  1833,  a memoir  to  the  French 
Academy,^  in  which,  following  up  the  doctrine  of  his  father  Avith 
regard  to  the  determination  and  distinction  of  the  type  of  parts  by 
the  particular  vessels  distributed  to  them,  he  endeavoured  to  shoAV 
some  new  points  of  analogy  betAveen  the  male  and  female  organs, 
and  to  develop  neAv  vieAVS  Avith  regard  to  the  origin  and  particular 
varieties  of  hermaphroditic  malformations.  With  Burdach,  he 
divides  the  Avhole  reproductive  apparatus  of  either  sex  into  three 

1 Home’s  Led.  on  Comp.  Anat.  vol.  ii.  pi.  v. 

2 We  have  already,  when  considering  spurious  hermaphroditism  in  the  female, 
mentioned  several  facts  illustrative  of  the  analogicial  peculiarities  in  structure  be- 
tween the  male  penis  and  female  clitoris  in  some  species  of  animals  ; and 
Burmeister,  who  regards  the  ovipositors  and  stings  of  female  insects  as  correspond- 
ing to  the  clitoris  in  the  female  Vertebrata,  has  pointed  out  a remarkable 
conformity  of  structural  type  between  its  valves  and  those  of  the  penis  of  the 
male  of  the  same  species. 

3 Burdach  {Phys.  s.  137)  considers  the  small  cutaneous  fold  situated  at  the 
orifices  of  the  vasa  deferentia,  and  Stiebel,  the  men\brane  placed  at  the  extremity 
of  the  urethra  (Meckel’s  Archiv  fur  Physiol.  Bd.  viii.  s.  207),  as  the  analogue  in 
the  male  for  the  female  hymen. 

^ Arch.  Gen.  de  Med.,  1833,  tom.  i.  306. 


512 


HERMAPHRODITISM. 


transverse  spheres,  and  into  six  portions  or  segments  in  all,  or  three 
on  each  side — viz.,  1 and  2,  the  deep  organs,  including  the  male 
testicles  and  female  ovaries  ; 3 and  4,  the  middle  organs,  or  male 
prostate  and  vesiculse  seminales,  and  female  uterus ; 5 and  6,  the 
external  organs,  comprehending  the  penis  and  scrotum  of  the  male, 
and  the  clitoris  and  vulva  of  the  female.  Each  of  these  portions  or 
segments  is,  M.  St.  Hilaire  points  out,  supplied  by  an  arterial  trunk 
peculiar  to  itself,  and  the  corresponding  organs  of  the  male  and 
female  by  corresponding  arterial  branches,  as  the  deep  organs  of 
lioth  sexes  by  the  two  spermatics,  the  middle  by  branches  of  the  two 
hypogastrics,  and  the  external  by  some  other  hypogastric  branches, 
and  by  the  external  pudics.  The  circumstance,  he  conceives, 
renders  all  the  segments  in  a certain  degree  independent  of  the 
others,  both  as  regards  their  development  and  existence,  and  allows 
of  the  occasional  evolution  of  any  one  or  more  of  them  on  a type 
of  sexual  structure  different  from  that  upon  which  the  others  are 
formed  in  the  same  individual. 

Though  assured!}^  we  cannot  subscribe  to  the  speculations  of  the 
elder  St.  Hilaire,  that  the  development  in  the  embryo  of  male 
testicles  or  female  ovaries,  and  consequently  the  whole  determina- 
tion of  the  sex,  is  originally  regulated  by  the  mere  relative  angle  at 
which  the  first  two  branches  of  the  spermatic  arteries  come  off,  and 
the  kind  of  course  which  they  follow^  (more  particularly  as  it  is  ad- 
mitted by  most  physiologists  that  the  blood-vessels  grow,  not  from 
their  larger  trunks  or  branches  towards  their  smaller,  but  from  their 
capillary  extremities  towards  their  larger  branches),  yet  we  believe 
that  the  doctrine  of  the  comparative  independence  of  the  different 
segments  of  the  reproductive  organs  pointed  out  by  the  son,  is  in 
its  general  principles  correct.  At  the  same  time  we  would  here 
remark  that  we  conceive  the  doctrine  would  have  been  founded 
more  on  truth  if  the  influence  of  the  nervous  branches  supply- 
ing the  different  reproductive  organs  had  been  taken  into  account 
along  with  that  of  their  arterial  vessels,  because,  as  we  shall  point 
out  when  speaking  of  the  causes  of  hermaphroditism,  there  appears 
to  be  some  connection  between  the  state  of  the  nervous  system  and 
the  degree  or  condition  of  sexual  development. 

^ Anat.  Phil.  tom.  i.  p.  359. — “ L’ordre  de  variations  des  sexes  tient  a la 
position  d’un  artere.  * * Le  plus  ou  le  nioins  d’ecartenient  des  deux  branches 

spermatiques  motive  effectivement  cette  preference.  Qne  les  deux  branches  de 
I’artke  sperrnatique  descendent  parallelement  et  de  compagnie,  cette  circonstance, 
je  le  repete,  cette  circonstance  donnele  .sexe  male  ; qu’elles  s’ecartent  a leuiqjoint 
de  partage,  nous  avons  le  sexe  femelle.” 


TRUE  HERMAPHRODITISM  WITHOUT  DUPLICITY. 


613 


The  consideration  of  the  preceding  analogies  in  structure  between 
the  male  and  female  organs  is  interesting  in  itself,  and,  so  far  as 
relates  to  our  present  subject,  important  in  this  respect,  that  it 
enables  us  to  understand  how  it  happens,  that,  without  any  actual 
monstrous  duplicity,  we  should  sometimes  find,  in  an  organisation 
essentially  male,  one  or  more  of  the  genital  organs  absent,  and  re- 
placed by  an  imperfect  or  neutral  organ,  or  by  the  corresponding 
or  prototypic  organ  of  the  opposite  sex,  and  vice  versa.  Hence 
there  is  no  difficulty  in  conceiving  that,  in  the  body  of  the  same 
individual,  the  primitive  structural  elements  of  these  parts  should 
occasionally,  in  one  or  more  points  or  segments,  take  on,  in  the  pro- 
cess of  development,  a different  sexual  type  from  that  which  they 
assume  at  other  points.  Indeed,  some  physiologists,  as  we  shall 
immediately  see,  deny  that  the  most  complete  hermaphroditic  mal- 
formations ever  consist  of  anything  excej^t  such  a want  of  conformity 
between  the  sexual  type  of  different  portions  of  the  reproductive 
apparatus. 

If  each  of  the  six  segments — and  we  believe  that  their  number 
might  be  shown  to  be  really  greater  than  this — is  thus  an  inde- 
pendent centre  of  development  in  the  formation  of  the  sexual  ap- 
paratus, and  is  consequently  liable  also  in  abnormal  cases  to  have 
its  own  particular  malformations,  and  to  assume,  either  alone  or 
along  with  some  of  the  other  segments,  a sexual  type  different  from 
the  remainder,  it  is  evident  that  we  may  have  as  many  varieties  of 
true  hermaphroditism,  without  any  real  duplicity,  as  it  is  possible  to 
conceive  differences  of  arrangement  among  these  six  segments. 
Again,  however,  one  or  more  of  these  segments  may  preserve  from 
development  its  original  indeterminate  or  neutral  sexual  type,  while 
the  others  are  variously  formed  either  upon  one  or  upon  both 
sexual  types  ; or  one  or  more  of  the  segments  may  have  evolved 
within  them  the  prototypic  or  analogous  organs  of  the  two  sexes,  as 
the  vasa  deferentia,  and  cornua  uteri ; and  if  we  consider  the 
different  arrangements  of  double  and  single  sexual  parts  that  might 
thus  occur  in  the  six  separate  segments,  we  may  gain  some  idea  of 
the  great  diversities  of  structure  in  the  sexual  parts  that  are  liable 
to  be  met  with  in  instances  of  true  hermaphroditism. 

This  doctrine  forms,  as  it  ajDpears  to  us,  the  most  sound  and 
rational  solution  of  the  nature  and  origin  of  many  forms  of  true 
hermaphroditism  which  physiological  science  is  capable  of  affording, 
with  our  present  limited  knowledge  of  the  laws  of  development ; 
and  its  application  to  the  explanation  of  the  different  varieties  of 


HERMAPHRODITISM. 


M4 

Lateral^  Transverse,  and  Vertical  hermaphroditism,  is  so  obvious  as 
only  to  require  to  be  alluded  to.  It  offers  to  us,  however,  no  insight 
into  the  probable  origin  of  those  varieties  of  double  her^iaphroditism 
in  which  there  is  an  actual  co-existence,  upon  one  or  upon  both  sides 
of  the  body,  or,  in  other  words,  in  the  same  segment  of  the  sexual 
apparatus,  of  such  corresponding  or  analogous  male  and  female 
organs  as  the  testes  and  ovaries.  We  can  only  refer  all  such 
instances  to  the  laws  which  regulate  the  occasional  production  of 
local  duplicities  in  different  other  organs  of  single  bodies,  and  at  the 
same  time  confess  our  present  ignorance  of  what  these  laws  are. 
We  know  that  various  individual  muscles,  nerves,  etc.,  are  not  un- 
frequently  found  double,  and  that  in  internal  organs  of  the  body 
examples  of  duplicity  in  individual  viscera  are  occasionally,  though 
rarely,  observed  in  the  heart,  tongue,  trachea,  oesophagus,  intestinal 
canal,  etc.  In  the  several  organs  composing  the  reproductive 
apparatus,  instances  of  similar  duplicity  would  seem  to  be  even  more 
common  than  among  any  other  of  the  viscera.  ’ Examples  of  three 
mammae  upon  the  same  person  are  mentioned  by  Bartholin,^  Borelli,^ 
Lanzoni,^  Drejer,*  Robert,*  Petrequin,®  and  others ) and  cases  in 
which  the  number  of  these  organs  was  increased  to  four  have  been 
recorded  by  Faber,®  Gardeux,®  Cabroli,^”  Lamy,“  Tiedemann,^^  Cham- 
pion,’^ Sinclair,^^  K Lee,^"*  and  Moore. An  insj:ance  in  which  even 
five  mammae  existed  upon  the  same  woman  is  reported  to  have  been 
seen  by  Gorre.^^  Valentin  and  Gunther  have  recorded  supposed 
cases  of  duplicity  in  the  male  penis ; and  Arnaud  has  related  an 
example  of  an  analogous  malformation  in  the  female  clitoris. 

^ Acta  Med.  Hafn.  tom,  iii.  obs.  93.  ^ Observ.  Ear.  cent.  i.  p.  55. 

^ E2)h.  Nat.  Cur.  Dec.  ii.  ann.  v.  obs.  55. 

^ A rch.  Gen.  de  Med.  tom.  xvii.  p.  88. 

^ Journ.  Gen.  de  Med.  tom.  c.  p.  57. 

® Gazette  Medicate  for  April  1837.  Three  distinct  mammae  in  a father,  and  in 
his  three  sons  and  two  daughters, 

7 Diet,  dcs  Sc.  Med.  tom.  xxxiv.  p,  529. 

® Ejdi.  Nat.  Cur.  Dec.  i.  ann.  ii.  p.  346. 

^ Journ.  de  Med.  de  Corvisart,  tom.  ix.  p.  378. 

Ohs.  Anat.  vii.  Fantoni  Anat.  p.  267, 

Zcitschrift  fiXr  Physiologic,  Bd.  v,  s.  110.  One  case  with  three,  and  three 
with  four  nipples.  In  one  case  the  malformation  was  hereditary. 

Diet,  dcs  Sc.  Med.  tom.  xxx.  pp.  377-78. 

Statistical  Account  of  Scotland,  xix.  p.  288. 

London  Med. -Chirurg.  Trans,  vol.  xxi.  p.  266. 

Lancet  for  F'eb.  24,  1838.  Diet,  des  Sc.  Mid.  tom.  xxxiv,  p.  529. 

Eyh.  Nat.  Cur.  Dec.  iii.  ann.  iii.  obs.  77. 

Cohen  vom  Stein,_lPiX\\Q,  1774,  p,  107.  Mew.  de  Chir.  tom.  i.  p.  374. 


DUPLICITY  OF  ANALOGOUS  ORGANS. 


515 


Weber  ^ met  with  a double  vesicula  seminalis  on  each  side ; and 
Hunter  2 alludes  to  the  occasional  occurrence  of  an  imperfect  super- 
numerary vas  deferens.  In  1833,  a case  of  a double  human  uterus, 
furnished  with  four  Fallopian  tubes  and  four  ovaries,  was  shown 
by  Professor  Moureau  to  the  Acad^mie  de  M^decine.^  Plasms'* 
dissected  the  body  of  a man  on  whom  he  detected  the  co-existence 
of  three  testicles ; the  additional  testicle  was  of  the  natural  form 
and  size,  and  was  furnished  with  a spermatic  artery  and  vein  that 
joined  in  the  usual  manner  the  aorta  and  vena  cava ; it  lay  in 
the  right  side  of  the  scrotum.  Arnaud  found,  on  dissection,  three 
testicles  in  a dog ; the  third  was  placed  in  the  abdomen,  and  of  the 
natural  consistence,  figure,  and  size ; it  was  furnished  with  a vas 
deferens.®  Other  instances  of  triple  and  quadruple  testicles  of  a 
more  doubtful  character,  inasmuch  as  the  observations  made  during 
life  were  not  confirmed  by  dissection  after  death,  are  related  by 
Voigtel,®  Sibbern,’^  Brown,®  Kennes,*'^  and  others.^®  Scharff^^  even 
gives  an  alleged  case  of  a man  with  five  testicles,  three  of  which  are 
stated  to  have  been  well  formed,  while  the  other  two  were  much 
smaller  than  natural.  And,  lastly,  Loder  is  said  to  have  exhibited 
to  the  Gottingen  Academy  drawings  taken  from  the  body  of  a male 
infant,  on  whom  all  the  sexual  apparatus  existed  double,  there  being 
two  penes,  a double  scrotum,  and  urinary  bladder,  and,  as  it  was 
supposed,  four  testicles. 

In  all  the  preceding  instances  the  local  duplicity  of  the  parti- 
cular reproductive  and  other  organs  adverted  to,  existed  independ- 
ently of  any  duplicity  in  the  body  in  general,  or  in  any  other 
individual  parts  of  it.  And  if  we  once  admit,  what  the  preceding 
instances  will  scarcely  allow  us  to  den}^  that  there  may  occur  a 
duplicity  of  some  of  the  male  sexual  organs  in  a male,  or  of  some 
of  the  female  sexual  organs  in  a female,  it  is  certainly  easy  to  go 
one  step  farther,  and  admit  that  the  double  organ  or  organs  may, 
however  rarely,  be  formed  in  other  instances  upon  an  opposite 
sexual  type.  If,  for  instance,  a division  or  duplicity,  original  or 
acquired,  of  a Wolffian  body,  or  of  the  neutral  organ  primarily 

* Salzhui'g  Medicinische  Zeitung,  1811,  s.  188. 

' Bell’s  Anatomy,  vol.  iii.  p.  428.  ^ Journ.  Hehdom.  tom.  x.  p.  168. 

* Ohs.  Med.  pars.  iv.  obs.  20.  ® Mem.  de  Chir.  s.  i.  p.  131. 

® Handhuch  der  Path.  Anat.  Bd.  iii.  s.  393.  ^ Acta  Hafn.  tom.  i.  p.  320. 

® New  York  Medical  Repository,  vol.  iv.  p.  801. 

Arch.  Gen.  de  Med.  tom.  xxiii.  p.  17. 

See  Haller’s  El.  Phys.  tom.  v.  pp.  411,  412  ; Arnaud’s  Chem.  de  Chirurg. 
tom.  i.  p.  128,  etc.  Eph.  Nat.  Cur.  Dec.  iii.  ann.  v.  vi.  obs.  89. 

Gottingen  Anz.  1802,  p.  466. 


516 


HERMAPHRODITISM. 


formed  on  its  inner  side,  or  if  any  other  cause,  be  capable  of  giving 
rise  to  the  development  of  two  testes  or  two  ovaries  upon  the  same 
side,  it  is  not  difficult  to  conceive  that  one  of  the  double  organs  may 
become  female  .and  the  other  male.  Indeed  all  our  knowledge  of 
the  unity  of  structure  and  development  between  the  various  analo- 
gous male  and  female  reproductive  organs,  as  well  as  the  fact  of  the 
occasional  replacement  of  an  organ  of  the  one  sex  by  that  of  the  other 
in  cases  in  which  the  sexual  type  is  entirely  single,  as  seen  in  in- 
stances of  Lateral  hermaphroditism,  would  lead  us,  d 'priori,  to  suppose 
that,  if  a local  duplicity  in  any  of  the  sexual  organs  was  liable  to 
occur,  this  duplicity  would  sometimes  show  itself  in  the  double 
organs  assuming  opposite  sexual  characters,  and  thus  constituting 
some  of  those  varieties  of  double  or  vertical  hermaphroditism  that 
we  have  already  had  occasion  to  describe. 

In  the  preceding  observations  we  have  proceeded  upon  the  opinion 
commonly  received  by  physiologists,  of  the  fundamental  unity  of 
sex  among  all  individuals  belonging  to  the  higher  orders  of  animals ; 
or,  to  express  it  otherwise,  we  have  assumed  that  each  individual  is, 
when  normally  formed,  originally  furnished  with  elemental  parts 
capable  of  forming  one  set  of  sexual  organs  only.  We  do  not  here 
stop  to  inquire  whether  this  single  sexual  type  is,  in  all  embryos, 
originally  female,  as  maintained  by  Eosenmuller,  Meckel,  Blainville, 
Grant,  and  others  ; or  of  a neutral  or  intermediate  character,  as  sup- 
posed by  the  St.  Hilaires,  Serres,  Ackermann,  Home,  etc.,  and  as 
we  are  certainly  ourselves  inclined  to  believe  it.^  On  this  subject, 
however,  a physiological  doctrine  of  a different  kind  has  been 
brought  forward  by  Dr.  Knox,  and  this  doctrine  is  so  intimately 
connected  with  the  question  of  the  nature  and  origin  of  true  herma- 
phrodites, that  we  must  here  briefly  consider  it. 

^ ]\Ieckel  {Dc  Duplicitate  Momlrosd,  p.  14)  and  Andral  {Anat.  Path.  tom.  i. 
p.  101)  assume  it,  after  Haller,  as  a fact,  that  a much  larger  proportion  of  monsters 
belong  to  the  female  than  to  the  male  sex  ; and  while  they  attribute  this  circum- 
stance to  the  genital  organs  in  these  beings  retaining,  from  the  general  defect  of 
development,  their  original  female  sexual  character,  they  at  the  same  time  con- 
sider this  circumstance  to  be  strongly  corroborative  of  this  particular  doctrine. 
Isid.  St.  Hilaire  has  shown  {Hist,  des  Anomal.  tom.  iii.  p.  387)  that  the  suppo.sed 
fact  itself  does  not  hold  true  in  respect  to  some  genera  of  monsters,  and  is  even 
reversed  in  others  ; and  he  doubts  if  it  be  of  such  a degree  of  generality  in  respect 
to  monsters' in  general  as  to  merit  being  raised  into  a teratological  law'.  If  the 
views  of  DIeckel  were  correct,  w'e  should  certainly  expect  at  least  that  spurious 
hermapliroditism,  where  the  development  of  the  sexual  parts  is  commonly  ab- 
normal from  defect,  should  be  much  more  frequent  in  the  female  than  in  the  male. 
The  list,  however,  of  recorded  cases  of  it  in  the  latter  is,  we  believe,  more  than 
double  the  number  of  it  in  the  former. 


ALLEGED  PRIMITIVE  DUPLICITY. 


517 


Dr.  Knox/  in  conformity  with  some  more  general  views  which 
he  entertains  on  transcendental  anatomy,  is  inclined  to  regard  the 
type  of  the  genital  organs  in  man  and  the  higher  animals,  as  in  tlie 
embryo,  originally  hermaphroditic,  or  as  comprising  elementary  yet 
distinct  parts,  out  of  which  both  sets  of  sexual  organs  could  be 
formed ; and  he  believes  that,  owing  to  particular  but  unknown 
circumstances,  either  the  one  or  the  other  only  of  these  sets  of  ele- 
ments comes  to  be  evolved  in  the  normal  course  of  development. 
In  those  abnormal  cases,  again,  in  which,  as  in  instances  of  double 
hermaphroditism,  more  or  fewer  of  both  sets  of  genital  organs  are 
present  upon  the  same  individual,  he  maintains  that  this  is  not  to 
be  considered  as  a malformation  by  duplicity,  but  is  only  a per- 
manent condition  of  the  original  double  sexual  type,  and  is  attribut- 
able to  the  simultaneous  development,  to  a greater  or  less  extent,  of 
both  the  male  and  female  sets  of  sexual  elements. 

This  doctrine  of  the  original  but  temporary  double-sexed  cha- 
racter of  all  embryos,  derives,  perhaps,  its  principal  support  from  a 
source  to  which  Dr.  Knox  does  not  advert — we  mean  the  existence 
of  this  as  the  normal  and  permanent  sexual  type  in  most  plants  and 
in  many  of  the  lower  orders  of  animals.  But  this  argument  by  ana- 
logy certainly  cannot  by  any  means  be  considered  as  a sufficient 
basis  for  the  establishment  of  so  broad  and  important  a generalisa- 
tion in  philosophical  anatomy.  Dr.  Knox  himself  seems  to  have 
been  induced  to  adopt  the  idea  principally  because  it  afforded  (when 
once  assumed  as  a fact)  a simple  and  elegant  solution,  upon  the 
laws  of  development,  of  the  occasional  occurrence  of  cases  of  true 
hermaphroditism ; and  in  doing  so,  he  appears  to  have  proceeded 
upon  the  mode  in  which  most  such  physiological  hypotheses  have 
been  made — viz.,  by  drawing  his  premises  from  his  deductions,  in- 
stead of  his  deductions  from  his  premises.  In  the  present  state, 
however,  of  anatomical  and  physiological  knowledge,  Dr.  Knox’s 
hypothesis,  however  ingenious  in  itself,  is  one  to  which  we  cannot 
subscribe  ; for,‘  first,  it  is  totally  opposed  to  all  the  facts  which  have 
been  ascertained,  and  all  the  direct  observations  which  have  been 
made  by  Kathke,  Meckel,  Muller,  Valentin,  and  other  modern  ana- 
tomists, upon  the  sexual  structure  of  the  embryos  of  the  higher 
animals  in  their  earliest  state  ; and,  secondly,  if  we  were  to  admit 
it  merely  as  a probable  hypothesis,  it  is  still,  even  in  this  respect, 
equally  as  incapable  as  the  old  doctrine  of  sexual  unity,  of  explain- 
ing all  the  cases  of  malformation  by  duplicity  of  the  genital  organs  ; 

^ Brewster’s  EcUnhimjh  Journal  of  Science,  vol.  ii.  p.  322. 


518 


HERMAPHRODITISM. 


for,  as  we  have  already  shown,  there  are  some  apparently  well- 
authenticated  instances  of  the  existence  of  three  or  four  testicles 
upon  the  same  man,  or  three  or  four  ovaries  upon  the  same  woman ; 
and  in  reference  to  all  such  cases  we  would,  if  Ave  proceeded  upon 
the  same  data  and  the  same  line  of  argument  as  those  adopted  by 
Dr.  Knox,  be  obliged  to  suppose  that  the  original  sexual  type  is 
not,  as  he  imagines,  double  only  as  respects  the  two  sexes,  but 
double  even  as  respects  each  sex,  and  that  all  embryos  had  originally 
not  simply  the  elements  of  two,  but  those  of  three  or  four  testicles 
and  ovaries.  In  explaining  such  cases  as  those  to  Avhich  we  allude. 
Dr.  Knox,  on  his  own  doctrine,  must  of  necessity  admit  the  exist- 
ence of  a malformation  by  duplicity  of  the  sexual  organs  in  question  ; 
and  if  we  grant  this  in  regard  to  these  instances,  it  is  surely  unne- 
cessary to  invent  a particular  and  gratuitous  hypothesis  for  the 
explanation  of  the  analogous  anatomical  abnormalities  observed  in 
hermaphroditism.  At  present  Ave  must,  Ave  believe,  merely  consider 
the  occurrence  of  anomalous  duplicity  of  the  sexual  organs,  and  of 
A^arious  other  individual  parts  of  the  body,  as  so  many  simple  em- 
pirical facts,  of  Avhich  Ave  cannot,  in  the  existing  state  of  our  knoAV- 
ledge,  give  any  satisfactory  explanation,  or,  in  other  Avords,  Avhich 
Ave  cannot  reduce  to  any  more  simple  or  general  fact ; though  from 
the  success  Avhich  has  attended  the  labours  of  many  modern  investi- 
gators in  this  particular  department  of  anatomy,  it  seems  to  us  not 
irrational  to  hope  that  ere  long  we  may  be  enabled  to  gain  much 
ncAv  light  upon  the  question  of  double  hermaphroditism  and  the 
AAdiole  subject  of  malformation  by  duplicity. 

ANATOMICAL  DEGREE  OF  SEXUAL  DUPLICITY  IN  THE  DIFFERENT 
FORMS  OF  HERMAPHRODITISM. 

Though  the  cases  Avhich  Ave  have  brought  forAvard  do  not  present 
any  instances  of  such  perfect  hermaphrodites  in  the  human  subject 
or  in  quadrupeds,  as  those  Avhich  are  represented  upon  the  ancient 
Greek  statues  and  medals,^  or  that  have  been  described  and  deli- 
neated by  Lycosthenes,  Par4,  Schenkius,  and  the  older  authors  on 

^ See  Winckelman,  Hist,  de  VArt,  tom.  i,  p.  364  ; and  Caylus,  Itccueil  d'An- 
tiquitts,  tom.  iii. ; Heinrich,  Commentatlo  qud  Hermaphroditorum  artis  antiques 
operibus  illustrium  origines  et  causes  cxplicantur : Hamburg,  1805.  Blumenbach, 
in  his  Specimen  Hist.  Nat.  Antiq.  artis,  Gottingen,  1808,  mentions  and  figures 
(pi.  i.  fig.  5,  p.  15)  a small  ancient  silver  cast  or  impression  of  a case  of  liypo- 
spadias  of  the  male  genital  pc'trts,  which  he  supposes  to  have  formed  a votive  offer- 
ing from  some  individual,  malformed  in  the  manner  represented. 


FALLACIES  OF  HERMAPHRODITISM. 


519 


monstrosities,  they  yet  present  to  us  a sufficient  number  of  instances 
in  which,  in  accordance  with  the  definition  we  have  previously  given 
of  true  hermaphroditism,  there  actually  co-existed  upon  the  body  of 
the  same  individual  more  or  fewer  of  the  genital  organs  both  of  the 
male  and  female. 

From  the  relations  and  size  of  the  bony  pelvis,  and  the  fact  of 
the  penis  and  clitoris  being  only  repetitions,  in  situation  and  struc- 
ture, and  organic  connections,  of  each  other,  in  the  two  sexes, 
it  is  useless,  perhaps,  to  expect  that  we  should  ever  find  in  any 
one  case  all  the  parts  of  both  sexes  present  at  the  same  time. 
For,  since  the  male  penis  is  only  a magnified  condition  of  the  female 
clitoris,  and  since  both  of  these  organs  are  connected  by  the  same 
anatomical  relations  to  the  same  part  of  the  pelvis,  it  would  almost 
require  some  duplicity  in  the  pelvic  bones  themselves  to  admit  of 
the  simultaneous  presence  of  both ; and  in  no  authentic  case  has 
any  approach  to  their  co-existence  upon  the  same  individual  been 
observed. 

Various  authors  who  have  written  upon  the  sifbject  of  hei‘- 
maphroditism  have  gone  so  far  as  to  endeavour  to  refer  all  instances 
of  it  to  some  one  or  other  of  those  varieties  that  we  have  described 
under  the  name  of  spurious.  Thus,  dogmatising  in  a spirit  of 
unphilosophical  scepticism.  Parsons^  and  Hill'  have  endeavoured  to 
show  that  all  reputed  hermaphrodites  are  only  malformed  females, 
having  a preternatural  development  of  the  clitoris,  and  in  some 
instances  with  the  ovaries  descended  into  the  labia.  Others,  on  the 
contrary,  as  Professors  Osiander^  and  Feiler,^  maintain  with  equal 
inaccuracy  that  every  supposed  instance  of  hermaphroditism  is  refer- 
able to  a hypospadiac  state  of  the  penis  and  scrotum,  in  persons 
that  are  in  other  respects  essentially  male. 

Various  physiologists,  again,  while  they  admit  the  occurrence  of 
all  the  different  varieties  of  spurious  hermaphroditism,  are  inclined 
to  deny  that  any  such  combinations  of  male  and  female  organs 
upon  the  same  body  as  those  which  constitute  our  several  varieties 
of  true  hermaphroditism,  are  ever  observed  to  occur  in  the  human 

^ Enquiry  into  the  nature  of  Hermaphrodites,  p.  145.  We  would  particularly 
point  out  the  cases  quoted  by  Dr.  Parsons  at  pp.  14,  26,  30,  88,  95,  130,  etc.,  of 
his  able  essay,  as  directly  contradictory  of  his  own  doctrine,  or  as  instances  of  her 
maphroditic  appearances  in  persons  not  of  the  female  but  of  the  male  sex. 

2 Revievj  of  the  Philosophical  Transactions. 

® Neue  DenTcwiirdiylc.  fur  Gcburtshulfe,  Bd.  i.  n.  8. 

^ Ueher  Angeb.  menschliche  Misbildung,  Landshut,  1820. 

89 


520 


HERMAPHRODITISM. 


subject,  or  among  the  higher  classes  of  animals.^  In  spite  of  the 
recent  accumulation  of  new  and  authentic  cases,  Professor  Muller 
of  Berlin  is,  in  particular,  in  his  excellent  treatise  on  the  develop- 
ment of  the  genital  organs,  published  in  1830,^  still  inclined  to 
coincide,  in  a great  degree,  in  this  opinion.  Few,  however,  I 
believe,  or  indeed  no  physiologists  now  refuse  to  admit  the  occa- 
sional occurrence  of  a combination  of  male  and  female  organs  upon 
the  same  individual,  when  that  combination  does  not  (as  in  Lateral 
and  Transverse  hermaphroditism)  imply  a true  sexual  duplicity  or 
repetition  of  any  of  the  corresponding  male  and  female  parts.  But 
some  still  altogether  doubt  the  probability  of  any  cases  of  our  third 
division  of  Double  or  Complex  hermaphroditism.  Certainly,  in  the 
examination  of  the  cases  referable  to  that  section,  and  especially  in 
reference  to  the  two  first  varieties  of  it,  a sufficient  degree  of 
attention  has  not  been  directed  to  the  accurate  anatomical  distinc- 
tion of  the  superadded  parts  supposed  to  exist,  from  others  with 
which  it  is  possible  to  confound  them.  We  shall  here,  therefore, 
shortly  recapitulate  and  inquire  into  some  of  the  principal  sources  of 
fallacy  that  are  apt  to  mislead  the  incautious  observer  in  the  exami- 
nation of  such  instances  as  those  to  which  we  allude,  and  which 
have  often  led  to  the  idea  of  sexual  duplicity,  when  the  sexual  type 
was  single  only,  but  malformed ; and  in  doing  so  we  shall  consider 
the  various  sources  of  error,  in  an  order  comformable  with  those 
divisions  of  double  hermaphroditism  that  we  have  previously  adopted 
— speaking  of  the  mistakes  which  may  and  have  been  committed 
in  judging  of  the.  supposed  co-existence,  Is^,  of  a female  uterus  and 
male  vesiculse  seminales  and  vasa  deferentia  ; 2d,  of  a female  uterus 
and  male  testicles,  etc. ; 36^,  of  both  testicles  and  ovaries. 

1.  FALLACIES  IN  JUDGING  OF  THE  ADDITION  OF  MALE  SEMINAL 
DUCTS  TO  A FEMALE  TYPE  OF  SEXUAL  ORGANS.^ 

Tliat  form  of  sexual  duplicity  which  consists  in  the  supposed 
superaddition  of  male  vesiculie  seminales  and  vasa  deferentia  to  an 
organisation  in  other  respects  female,  appears  to  have  been  hitherto 
observed  only  among  the  Ruminantia,  or  in  free-martin  cows.  In 
judging  of  the  reality  of  this  variety  of  hermaphroditic  malformation 

^ Thus  Portal,  Anat.  Med.  tom.  v.  p.  474  ; Haller,  El.  Phijs.  tom.  viii.  p.  7, 
“ merito  dubitatur;”  Voigtel.  llandbuch  dcr  Path.  Anat.  Bd.  iii.  s.  364  ; Law- 
rence, Art.  “Generation,”  in  Rees’  Cydo]iccdia. 

2 Bildungsgcschichte  dcr  Gcnitcdicn,  etc.  ; Physiology,  by  Baly,  vol.  ii.  p.  640. 

^ See  anteriorly,  p.  459. 


EKKOIIS  FROM  DUCTS  OF  GAERTNER. 


521 


in  any  given  case,  in  that  animal,  there  is  one  source  of  fallacy  that 
re(|uires  to  be  particularly  guarded  against,  and  the  consideration  of 
which  suffices  fully  to  explain  most  if  not  all  the  recorded  examples 
of  this  malformation.  In  the  female  sexual  parts  of  some  Eumi- 
nantia  and  Pachydermata,^  but  particularly  in  the  domestic  cow  and 
sow.  Dr.  Gaertner  of  Copenhagen  pointed  out  in  1822^  the  exist- 
ence of  two  canals  or  ducts  which  have  since  that  time  been  gener- 
ally described  under  his  name.  On  each  side  of  the  body,  one  of 
these  ducts  arises  in  the  vicinity  of  the  ovary,  or  toward  the  fimbri- 
ated extremity  of  the  Fallopian  tube,  runs  down  first  in  the  dupli- 
cature  of  the  broad  ligament,  and  afterwards  in  the  substance  of  the 
parietes  of  the  uterus  and  vagina,  to  near  the  meatus  urinarius,  and 
there  opens  into  the  vaginal  cavity.  Each  duct  communicates  with 
several  small  glands,  follicles,  or  cysts,  that  are  scattered  along  its 
course,  and  which  perhaps  may  not  be  improperly  described  as  diver- 
ticula from  the  ducts  themselves,  or  nascent  vesiculse  seminales. 
Now  when  we  consider  the  relations  of  those  imperfect  ducts  and 
cysts  that  are  occasionally  observed  in  the  free-martin  cow,  situated 
along  each  side  of  the  defectively  developed  uterus,  and  which  Mr. 
Hunter  has  described  as  male  vasa  deferentia  and  vesiculae  seminales, 
it  seems  to  us  that  these  supposed  male  organs  are  only  in  reality 
the  ducts  of  Gaertner,  with  their  accompanying  follicles  or  cysts, 
existing  perhaps  in  a preternaturally  developed  and  dilated  condi- 
•tion.  They  correspond  in  their  origin,  course,  and  position,  with  the 
canals  and  cysts  discovered  by  Gaertner ; and  certainly,  in  the 
present  state  of  our  knowledge,  we  are  fully  entitled  to  refer  them 
to  this  normal  portion  of  the  female  structure,  rather  than  to  regard 
them  as  abnormal  and  superadded  male  organs,  and  as  affording,  in 
consequence,  an  example  of  true  sexual  duplicity. 

Before  leaving  the  fallacy  which  we  have  to  guard  against  in 
confounding  the  ducts  of  Gaertner  in  free-martin  cows  with  the 
male  seminal  canals,  it  is  necessary  also  to  observe,  that,  as  was  long 
ago  suggested^  by  Dr.  Jacobson  of  Copenhagen,  and,  as  we  have 
alread}^  seen,'^  has  been  latterly  proved  by  Kobelt,  F.  Meckel,  and 

^ M.  Delmas  seems  to  have  observed  a somewhat  similar  structure  in  the  kan- 
garoo {Ephem.  Med.  de  MontiJclicr,  tom.  v.  p.  115)  ; and  Coste,  in  the  sheep 
See  Comptes  llendus  de  V Academic  des  Scic'ikcs  for  1839,  p.  334. 

^ Anatomi^k  Beskrivelse  over  ct  ved  Nogle  Dyr-Arfxrs  idcrus  undersogt  Glan- 
dulost  organ,  etc.,  Copenhagen,  1822  ; Edin.  Med.  and  S^irg.  Journ.,  vol.  xxi. 
p.  460. 

^ Journal  de  VInstitut,  tom.  ii.  p.  160  ; and  Die  Okensehen  K6rj)er,  etc., 
Copenhagen,  1830. 

^ See  antecedent  section  on  the  Unity  of  Type,  Wolffian-  Bodies,  etc.,  p.  504,  etc. 


522 


HERMAPHRODITISM. 


others,  these  canals  are  now  generally  considered  by  anatomists  as 
merely  permament  remains  of  the  ducts  of  the  Wolffian  bodies.  If, 
however,  it  should  ever  happen  that  further  and  more  accurate 
observations  prove  the  two  to  be  different,  then  the  possible  perma- 
nent state  of  the  ducts  of  the  Wolffian  bodies  must  be  looked  upon 
as  affording  another  source  of  error,  by  which  we  may  deceive  our- 
selves in  judging  of  sexual  duplicity  from  the  supposed  superad- 
dition of  male  seminal  ciinals  to  a female  sexual  apparatus. 

In  the  course  of  the  preceding  pages  we  have  had  occasion 
to  allude  to  cases  in  the  human  subject,  and  in  the  dog  and 
sheep,  in  which  vasa  deferentia  were  stated  to  have  existed  in  the 
same  individual  along  with  Fallopian  tubes.  In  these  instances, 
the  supposed  male  seminal  ducts  were,  in  all  probability,  canals 
analogous  to  those  described  by  Gaertner  in  the  cow  and  sow ; and 
in  connection  with  this  inquiry  it  is  interesting  to  remark  that 
Malpighi,^  who  seems  to  have  been  w^ell  acquainted  with  the 
existence  of  these  ducts  in  the  cow,  has  suggested  that  they  may 
also  exist  in  a more  obscurely  developed  state  in  the  human  female, 
and  may  perhaps  be  identified  with  the  ramose  lacunae  described  by 
De  Graaf,  Bartholin,  Eiolan,  etc.  Indeed,  A.*C.  Baudeloque  has,  in 
a case  published  in  the  Revue  Mddicale  for  March  1826,  described  a 
human  uterus  which  contained  in  its  parietes  a canal  coming  from 
the  region  of  the  right  Fallopian  tube,  and  opening  upon  the 
internal  surface  of  the  cervix  uteri ; and  Moureau  and  Gardien  seem 
to  have  met  with  a second  similar  instance.*  Were  these  canals  in 
the  human  female  not  truly  the  same  as  the  canals  of  Gaertner  in 
the  cow,  etc.,  and  consequently  the  persistent  remains  of  the  ducts 
of  the  Wolffian  bo  ly  1 And  would  not  such  cases  of  abnormal 
persistence  of  these  ducts  or  canals  in  woman  be  more  frequently 
detected,  if  the  attention  of  anatomists  were  more  specially  directed 
to  the  inquiry  % 

2.  FALLACIES  IN  THE  SUPPOSED  CO-EXISTENCE  OF  A FEMALE 
UTERUS  WITH  TESTICLES  AND  OTHER  ORGANS  OF  A MALE 
SEXUAL  TYPE. 

AVe  have,  in  a previous  part  of  this  memoir  (p.  460  to  p.  470), 
adduced  above  twenty  different  instances  in  the  human  subject, 
and  in  the  quadruped,  in  which  a large-sized  uterus,  or  botli  a 

^ Philosophical  Transactions  for  1684,  p.  634, 

2 Medical  Jicpositonj  for  1826,  p.  571. 


EURORS  FROM  MALE  UTERUS. 


523 


uterus  and  Fallopian  tubes,  were  described  as  having  been  found 
upon  the  bodies  of  individuals  that  were  in  other  respects  essentially 
males. 

In  reference  to  these  instances,  it  may  be  doubted  whether 
the  sexual  organisation  of  the  malformed  animal  was  not  entirely 
male,  the  large  but  imperfect  uterus  which  is  present  being  merely 
a preternaturally  or  abnormally  developed  state  of  the  small 
prostatic  vesicle  or  utricle  normally  found  in  the  organisation  of 
the  male.^  Thus,  in  the  case  detailed  by  Ackermann,  the  only 
male  sexual  organ  that  was  entirely  deficient  was  the  prostate, 
and  the  only  reputed  female  organ  which  was  present  was  an 
imperfect  cystiform  uterus,  having,  as  in  the  normal  state  of  the 
prostatic  vesicle,  the  vasa  deferentia  penetrating  through  its 
substance  without  opening  into  its  cavity,  and  ultimately  termi- 
nating, as  the  orifice  of  the  male  prostatic  utricle  actually  does, 
in  the  posterior  part  of  the  urethra.  In  the  analogous  instance 
quoted  in  a preceding  page  (p.  465)  from  Steghlener,  a similar 
arrangement  of  parts  was  observed  ; and  in  that  case  there  was, 
in  the  enlarged  ureters  and  renal  infundibula,  perhaps  sufficient 
evidence,  as  we  shall  afterwards  point  out  when  speaking  of  the 
probable  causes  of  hermaphroditism,  of  a distending  power  having 
acted  upon  the  whole  internal  surface  of  the  urinary  and  genital 
canals,  and  with  so  great  a force  (we  may  in  the  meantime  allow) 
as  to  be  capable  of  producing  a morbid  dilatation  and  enlargement 
of  the  cavity  and  substance  of  the  prostatic  vesicle.  But,  even 
granting  that  the  instances  given  by  Ackermann  and  Steghlener, 
and  most  other  cases,  are  not  at  all  satisfactory  in  regard  to  the 
reputed  existence  in  them  of  a variety  of  true  sexual  duplicity, 
and  allowing,  what  seems  probable,  or  indeed  certain,  that  the 
misshapen  and  imperfect  uteri  in  these  examples  were  formed  by  a 
simple  dilatation  and  enlargement  of  the  natural  male  utricle  or 
prostatic  vesicle,^  there  are  still  some  other  cases  pertaining  to 

^ See  antecedently  its  description,  p.  505,  etc. 

2 In  Ackermann's  case,  the  dilated  cystoid  utricle  perhaps  represented  the 
vagina  more  than  the  uterus,  or  the  lower  partion  of  the  uterus  more  than  its 
fundus  ; and  the  same  remark  applies,  with  probably  great  truth,  to  Steghlener’s 
hermaphrodite,  where  the  vasa  deferentia  opened  into  the  cavity  of  the  so-called 
uterus — as  the  analogous  Wolllian  ducts  normally  do  into  the  utricle  of  the  hare 
and  rabbit,  and  possibly  in  the  very  early  human  embryo.  If  the  upper  portion 
or  fundus  of  the  uterine  organ  had  been  represented  in  these  cases,  that  part  of 
the  cystoid  utricle  would  in  all  likelihood  have  been  double  or  bifurcated  as  the 
uterus  is  in  the  early  female  embryo.  In  the  human  hermaphrodite,  the 
ordinary  site  of  junction  of  the  WolfTian  ducts,  or  seminal  tubes,  with  the  genital 


524 


, HERMAPHRODITISM. 


this  division  which  scarcely  fall  within  the  hounds  of  the  expla- 
nation, that  the  form  of  hermaphroditic  malformation  in  question 
always  consists  of  nothing  more  than  a male  organisation,  with 
the  usual  normal  male  utricle  developed  to  an  unusual  and  abnormal 
size. 

In  the  adult  male  goat,  and  in  some  other  animals,  the  horns  of 
the  bilobed  prostatic  utricle  sometimes  run  and  stretch,  in  their 
natural  state  of  conformation,  alongside  the  vasa  deferentia  up  even 
to  the  testicles  themselves.  We  cannot,  therefore,  be  surprised  at 
finding  that  in  cases  of  the  present  division  of  hermaphroditism,  such 
as  the  goat  described  by  Gurlt  (see  p.  461)  and  represented  in  our 
W.oodcut  (Fig.  14),  the  so-called  Fallopian  tubes,  or  perhaps  more 
properly  the  elongated  cornua  uteri,  passed  through  the  inguinal 
rings,  and  were  ultimately  affixed,  as  they  often  are  in  this  division 
of  these  malformations,  to  the  epididymes  of  the  testicles.  In  all 
this  structural  arrangement  there  is  nothing  incompatible  with  the 
idea  that  the  uterus  and  uterine  cornua,  which  were  present,  con- 
sisted only  of  a preternaturally  enlarged  state  of  the  i^rostatic  or 
male  utricle.  But  in  the  adult  male  human  subject,  the  male  utricle 
is  rounded  at  its  fundus,  and  gives  off  no  cornua  or  appearances  of 
Fallopian  tubes.  Yet,  in  the  division  of  hermaphroditic  malforma- 
tions of  which  we  are  at  present  treating — viz.  those  consisting  of  a 
male  organisation,  with  the  addition  to  it  of  a large  uterus,  etc. — we 
find  several  cases  in  our  own  species  in  which  the  uterus  that  existed 
was  provided  with  cornua  and  Fallopian  tubes.  Thus,  in  the  person 
dissected  by  Petit,  the  imperfect  uterus  VAas  furnished  with  two  per- 
forate Fallopian  tubes  of  three  and  a half  inches  in  length,  and  at 
the  same  time  it  is  distinctly  stated  that  not  only  the  prostate 
gland,  but  the  vesiculse  seminales  and  vasa  deferentia  were  also  pre- 
sent. The  vasa  deferentia,  between  their  origin  from  the  testicles 
and  tlieir  urethral  termination,  were  each  above  seven  inches  Ions:, 
and  they  entered  the  urethra  by  two  apertures  that  were  quite  dis- 
tinct and  separate  from  the  orifice  of  the  uterus,  which  opened  into 
the  urethral  canal  at  a point  between  the  neck  of  the  bladder  and  the 

sinus,  may  sometimes  in  such  exceptional  cases,  be  regulated — 1.  By  the  very 
early  period  at  which  the  arrestment  of  development,  and  consequent  persistence 
of  embryonic  type,  takes  place  ; and  2.  By  the  degree  of  evolution  wliieh  tlie 
malformed  parts  subsequently  undergo.  In  Vrolik’s  case  of  double  hermajdiro- 
dite — already  cited  in  a previous  section,  p.  478,  the  Wolflian  duct,  or  vas 
deferens,  on  the  right  or  most  developed  side,  opened,  as  iisual,  into  the  vagina  ; 
while,  on  the  left,  or  least  developed  side,  it  opened  into  the  angle  of  the 
uterus. 


PERSISTENCE  OF  EMBRYONIC  TYPES. 


525 


prostate.  In  this  case  the  Fallopian  tubes  of  the  uterus  can  scarcely 
be  considered  as  merely  formed  at  the  expense  of  the  normal  male 
or  prostatic  utricle ; and  consequently  we  can  only,  in  one  sense^ 
consider  the  Fallopian  tubes  or  cornua  uteri  as  a siipjper addition  to, 
and  not  a transformation  of,  the  male  structures ; or,  in  other  words, 
we  may  so  far  look  upon  the  above  as  an  instance  of  duplicity  in  a 
part  of  the  sexual  apparatus. 

The  same  reasoning  and  remarks  might  be  shown,  if  it  were 
necessary,  to  apply  in  a still  greater  degree  to  the  analogous  example 
in  the  human  subject  given  by  Professor  Mayer,  and  where  he  found 
upon  an  infant  six  months  old,  superadded  to  a complete  male 
organisation,  a vagina,  uterus,  and  two  Fallopian  tubes,  furnished 
with  dilated  sacs  as  infundibuliform  extremities.  See  the  descrip- 
tion and  delineation  in  a preceding  section  (])nge  4G8,  Fig.  17). 
In  an  interesting  case  of  the  same  description  detailed  by  Betz,^ 
that  anatomist  found  on  the  body  of  a young  infant  a male  organi- 
sation (testis,  vasa  deferentia,  etc.),  with  a uterus  in  the  site  of  the 
prostatic  vesicle,  as  large  as  the  female  uterus  in  children  of  the 
same  age.  Further,  this  uterus  had  Fallopian  tubes  running  from 
it  on  either  side,  along  with  the  vasa  deferentia,  to  the  testicles ; 
and  of  these  Fallopian  tubes,  the  one  on  the  right  side,  at  least, 
ended  at  the  epididymis  of  the  testis,  in  an  imperfect  infundibuli- 
form extremity  or  dilatation. 

In  all  these  latter  instances,  the  form  and  type  of  the  uterus 
and  uterine  tubes  were  much  greater  and  more  perfect  than  could 
be  produced  by  simple  enlargement  and  dilatation  of  the  human 
prostatic  vesicle  or  male  utricle,  such  as  we  see  it  in  the  adult. 
But  still,  after  all,  this  does  not,  we  opine,  remove  such  cases  of 
hermaphroditic  malformation  from  the  category  of  those  that  consist 
merely  of  a male  organisation,  with  the  superaddition  of  an  enlarged 
and  developed  state  of  the  normal  male  utricle  and  its  elements. 
In  the  very  early  mammalian  male  embryo,  as  we  have  already 
stated  (p.  504),  hollow  filaments  or  ducts  corresponding  to  the 
Fallopian  tubes  are  present,  and,  in  the  human  and  some  other 
embryos  they  very  early  also  disappear,  leaving  the  male  utricle 
without  any  appearance  of  such  structural  appendages.  In  the  cases 
of  Petit,  Mayer,  Betz,  etc.,  these  transitory  uterine  appendages  were 
unremoved,  in  consequence  of  some  contemporaneous  arrest  or  error 
in  development ; they  consequently  remained  beyond  the  period  of 
intra-uterine  life,  and  at  the  same  time  they  grew,  like  most  other 
1 Archivs far  Anatomtc,  etc.,  1850,  p.  65. 


526 


HERMAPHRODITISM. 


malformed  or  persistent  embryonic  structures,  with  the  general 
growth  of  the  body,  and  of  the  parts  more  immediately  surrounding 
them.  Hence,  in  these  instances  we  have,  in  addition  to  the  usual 
male  organs,  apparently  female  uterine  structures,  incapable  of  being 
imitated  by  any  mere  enlargement  and  dilatation  of  the  adult 
prostatic  or  male  utricle ; but  essentially  consisting  of  a persistent 
state  of  those  transitory  conditions  of  the  male  utricle  and  its 
appended  tubes,  that  exist  in  some  of  the  earliest  stages  of  embryonic 
development.  Further,  in  reference  to  the  general  imperfection  of 
the  sexual  parts  observed  in  these  and  in  other  examples  of  herma- 
phroditic malformation  in  the  present  and  neighbouring  sections,  let 
me  here  again  repeat,  as  one  of  the  general  laws  to  which  these 
malformations  are  subject,  an  important  statement  already  made — 
viz.  that  whenever  we  find  the  development  of  the  sexual  organs  of 
an  individual,  whether  male  or  female,  restrained  or  arrested,  so  as 
to  be  below  the  normal  type  or  standard,  some  of  the  organs  of  the 
opposite  sex  will,  in  the  same  individual,  be  observed  to  be  de- 
veloped, as  it  were,  in  excess,  or  above  their  normal  type  or 
standard  ; and,  as  in  the  preceding  instance,  this  apparent  excess 
will  usually,  we  believe,  be  found  to  arise  from  the  mere  permanence 
in  the  adult  of  some  early  and  transitory  form  of  organisation  in  the 
embryo. 

3.  FALLACIES  IN  THE  SUPPOSED  CO-EXISTENCE  OF  TESTICLES 
AND  OVARIES. 

In  several  of  the  instances  already  described,  from  p.  4 70  to 
p.  479,  and  in  which  there  was  supposed  to  be  a co-existence  of 
both  testicles  and  ovaries  upon  the  same  side  or  sides  of  the  body, 
it  seems  highly  probable  that  there  has  been  occasionally  a fallacy 
in  the  observation,  owing  to  a want  of  knowledge  of  some  anatomical 
circumstances  that  are  liable  to  lead  us  into  error  in  makincr  an 

O 

examination  of  such  a case. 

We  have  repeatedly  had  occasion  to  allude  to  the  existence  in 
the  foetal  state,  and  in  both  sexes,  of  the  AYolffian  bodies,  wdiich  are 
placed  one  along  each  side  of  the  spine,  and  occupy  at  an  early 
period  in  the  embryo  a great  part  of  the  cavity  of  the  trunk.  These 
bodies  shrink  and  alter  in  the  natural  course  of  development,  but 
never  altogether  disappear  in  man,  and  in  the  quadruped  leave 
vestiges  of  their  presence  even  in  the  adult  animal.^ 

^ See  the  description  which  I have  given  of  the  Wolffian  bodies,  and  their 


CO-EXISTENCE  OF  TESTICLES  AND  OVARIES. 


527 


This  particular  type  of  structure,  which  is  comparatively  so  very 
large  in  the  embryo,  may,  like  every  other  type  of  the  foetus,  from 
an  impediment  or  arrest  in  the  natural  course  of  the  changes  occur- 
ring in  the  development  of  the  body  in  general,  or  of  the  genital 
organs  in  particular,  remain  occasionally,  we  have  every  reason  to 
believe,  permanently  enlarged  in  one  or  all  of  its  parts,  and  thus,  by 
its  presence  in  the  animal,  lead  us  to  suppose  that  a rudimentary 
testicle  exists  in  an  otherwise  well-marked  female ; or,  on  the  other 
hand,  that  an  ovary  exists  in  an  otherwise  well-marked  male. 
Both  of  these  mistakes  will  be  the  more  apt  to  be  committed  if 
the  original  excretory  duct  of  the  Wolffian  body  remains,  for  it 
may  give  the  appearance  of  the  addition  of  a vas  deferens  to  the 
supposed  testicle,  or  of  an  imperfect  Fallopian  tube  to  the  supposed 
ovary. 

The  error,  also,  of  confounding  a permanently  large  Wolffian 
body  with  the  testicle  will  be  the  more  liable  to  occur,  in  conse- 
quence of  the  former  body  being  naturally  composed  of  an  accu- 
mulation of  convoluted  diverticula  which  might  be  readily  mis- 
taken by  an  incautious  observer  for  the  seminiferous  ducts  of  the 
latter. 

There  is  certainly  strong  cause  for  doubting  whether,  in  some 
of  the  cases  that  we  have  cited  of  the  supposed  co-existence  of 
testicles  and  ovaries  upon  the  same  side,  the  permanent  embryonic 
type  of  the  Wolffian  bodies  and  their  ducts  had  not  been  mistaken 
either  for  testicles  and  vasa  deferentia,  while  the  sexual  organisa- 
tion was  otherwise  truly  female,  or  for  ovaries  and  Fallopian  tubes, 
while  the  type  of  structure  was  in  other  respects  strictly  that  of  the 
male.  This  remark  may  perhaps  with  confidence  be  applied,  for 
example,  to  the  case  of  the  free-martin  described  by  Mr.  Hunter 
(see  p.  472)  ; and  in  this  and  in  most  other  similar  instances  the 
suj)posed  testicles  and  ovaries  have  not  been  examined  with  any- 
thing like  sufficient  anatomical  accuracy.  At  the  same  time,  how- 
ever, it  appears  to  us  quite  impossible  to  explain  away  all  the  re- 
corded cases  of  the  supposed  co-existence  of  testicles  and  ovaries  upon 
this  principle.  The  cases,  for  example,  of  testes  and  ovaries  observed 
on  the  same  side  by  Mascagni  and  Vrolik  (see  pp.  471,  478),  cannot 
be  set  aside  b}'^  such  an  interpretation.  And  in  reference  to  this 
point,  we  would  further  particularly  observe  that  the  consideration 
of  the  relative  'position  occupied  by  the  reputed  testicles  and  ovaries 

persistent  conditions  in  the  adult  female  and  male,  in  a preceding  section, 
p.  502,  etc. 


528 


HERMAPHRODITISM. 


may  perhaps  afford  us  a useful  guide  in  cases  of  doubt.  In  some  of 
the  instances  that  have  been  previously  cited,  the  relative  situation 
of  the  supposed  testicles  and  ovaries  was  exactly  such  as  the  Wolf- 
fian bodies  are  known  to  bear  to  these  parts.  In  other  instances, 
however,  as  in  the  ape  described  by  Dr.  Harlan,  the  relative  situa- 
tion in  which  the  testicles  and  ovaries  were  found  was  that  which 
they  occupy  in  the  perfectly-formed  male  and  female  ; and  in  such  a 
case  as  this  it  would  surely  be  over-sceptical,  and  at  the  same  time 
in  opposition  to  all  that  we  yet  know  of  the  history  of  the  Wolffian 
bodies,  to  suppose  that  these  bodies  had  imitated  the  testicles  so 
far  as  to  move  out  of  their  original  locality  and  travel  downwards 
through  the  inguinal  rings.  At  the  same  time,  we  must  recollect 
that  in  this  case  the  distinctive  anatomical  structure  both  of  the 
testicles  and  ovaries  seems  to  have  been  satisfactorily  made  out,  in 
so  far  that  the  former  are  described  as  “perfectly  formed,”  and  the 
latter  as  having  “ minute  ova  visible  in  them.”  “ The  male  and 
female  organs  of  generation,”  Dr.  Harlan  adds,  “ were  as  completely 
perfected  as  could  have  been  anticipated  in  so  young  an  individual, 
and  resembled  those  of  otlier  individuals  of  a similar  age.”  Now  if 
we  once  admit  in  this,  or  in  any  one  other  particular  instance,  that 
the  evidence  of  the  co-existence  of  testicles  and  ovaries  is  satisfac- 
tory, then  certainly  we  may  in  any  equivocal  case  be  entitled  to 
doubt,  until  we  have  some  more  sufficient  criterion  for  distinction 
pointed  out,  whether  the  dubious  double  bodies  that  we  may  meet 
with  be  a rudimentary  testicle  or  ovary  conjoined  with  an  imperfect 
Wolffian  body,  or  really  a true  instance  of  the  presence  both  of 
testicles  and  ovaries  upon  one  or  upon  both  sides  of  the  body  of 
the  same  individual. 

PHYSIOLOGICAL  DEGREE  OF  SEXUAL  PERFECTION  IN 
HERMAPHRODITES. 

Among  those  lower  tribes  of  animals,  such  as  the  Abranchial 
Annelida,  Pteropoda,  etc.,  that  are  naturally  hermaphrodite,  every 
individual  is  in  itself  a perfect  representation  of  the  species  to 
which  it  belongs.  In  the  higher  orders,  however,  in  which  tlie 
distinction  and  separation  of  the  sexes  come  to  be  marked,  each 
individual,  being  either  solely  male  or  solely  female,  can,  as  has 
often  been  remarked,  be  regarded  only  as  representing  one-half  of 
its  entire  species.  In  most  instances  of  hermaphroditism  among 
these  more  perfect  animals,  the  malformed  being  does  not  even 


PREGNANCY  IN  SUPPOSED  HERMAPHRODITISM. 


529 


attain  to  this  degree  of  perfection,  but  is  in  general  so  defectively 
constituted  as  not  to  have  the  proper  physiological  characters  and 
attributes  of  either  sex.  In  cases  of  spurious  hermaphroditism  it 
would  appear  that  sometimes,  though  the  copulative  or  external 
sexual  parts  are  greatly  and  variously  malformed,  the  internal  or 
proper  reproductive  organs  are  developed  with  sufficient  perfection 
to  enable  them  to  perform  the  functions  belonging  to  them.  AYe 
have  very  little  proof,  however,  that  in  any  instances  of  what  we 
have  described  as  true  hermaphroditism,  the  apparatus  of  either  sex 
is  ever  formed  with  such  anatomical  perfection  as  to  empower  the 
malformed  being  to  bear  a successful  part  in  the  reproductive 
function.  Indeed  in  all,  or  in  almost  all,  cases  belonging  to  this  last 
order  of  hermaphroditism,  the  individual  who  is  the  subject  of  the 
malformation  may,  with  much  more  than  poetical  truth,  be  described, 
both  anatomically  and  physiologically,  as  in  the  words  of  Ovid — 

Concretus  sexu,  sed  non  perfectus  ntroqiie, 

Anibiguo  venere,  neutro  potiundus  amore. 

There  is  on  record  one  remarkable  instance  of  apparent  ex- 
ception to  this  general  observation,  a notice  of  Avhich  Ave  have 
reserved  for  this  place,  on  account  of  the  want  of  any  such  precise 
knoAvledge  of  the  true  anatomical  peculiarities  of  the  case  as  might 
enable  us  to  refer  it  to  the  section  Avhich  it  ought  to  occupy  in  our 
classification.  The  case  to  which  we  allude  Avas  described  by  Dr. 
Hendy  of  NeAV  York,  in  a letter  dated  from  Lisbon  in  1807,  and 
the  subject  of  it  Avas  a Portuguese,  tAventy-eight  years  old,  of  a tall 
and  slender  but  masculine  figure.'  “ The  penis  and  testicles,”  to 
adopt  the  Avords  of  Dr.  Hendy’s  OAvn  narrative,  “ Avith  their  common 
covering,  the  scrotum,  are  in  the  usual  situation,  of  the  form  and 
appearance,  and  very  nearly  of  the  size,  of  those  of  an  adult.  The 
prseputium  covers  the  glans  completely,  and  admits  of  being  parti- 
ally retracted.  On  the  introduction  of  a probe,  the  male  urethra 
appeared  to  be  pervious  about  a third  of  its  length,  beyond  Avhich 
the  resistance  to  its  passage  Avas  insuperable  by  any  ordinary  justi- 
fiable force.  There  is  a tendency  to  the  groAvth  of  a beard,  Avhich 
is  kept  short  by  clipping  Avith  scissors.  The  female  parts  do  not 
differ  from  those  of  the  more  perfect  sex,  except  in  the  size  of  the 
labia,  Avhich  are  not  so  prominent,  and  also  that  the  Avhole  of  the 
external  organs  appear  to  be  situated  nearer  the  rectum,  and  are  not 
surrounded  Avitli  the  usual  quantity  of  hair.  The  thighs  do  not 

^ Ncio  York  Medical  llcpository,  vol.  xii.  p.  86. 


530 


HERMAPHRODITISM. 


possess  the  tapering  fulness  common  to  the  exquisitely  formed 
female;  the  ossa  ilii  are  less  expanded,  and  the  breasts  are  very 
small.  Tn  voice  and  manners  the  female  predominates.  She  men- 
struates regularly,  was  twice  j^regnant,  and  miscarried  in  the  third 
and  fifth  months  of  gestation.  During  copulation  the  penis  becomes 
erect.  Tliere  has  never  existed  an  inclination  for  commerce  with 
the  female  under  any  circumstances  of  excitement  of  the  venereal 
passion.”  In  the  preceding  case,  if  we  may  confidently  trust  to  the 
account  given  of  it,  we  have  ample  proof  of  the  existence  of  the 
internal  female  sexual  organs,  in  the  circumstances  of  menstruation 
and  impregnation  taking  place  ; and  at  the  same  time  there  appears 
considerable  evidence  for  believing  that  some  of  the  male  organs 
were  present.  For,  even  if  we  were  to  argue  that  the  bodies  pre- 
sent in  the  scrotum  or  united  labia  might  be  ovaries  and  not  testicles 
— or,  as  happened  in  Vrolik  and  Sir  Astley  Cooper’s  cases,  mere 
masses  of  fat — and  that  the  supposed  semi-perforate  penis  was  only 
an  enlarged  clitoris,  still  the  masculine  figure  of  the  individual,  the 
imperfect  beard,  the  narrowness  of  the  pelvis,  and  the  form  of  the 
lower  extremities,  would  tend  to  indicate  the  probable  existence  of 
the  rudiments  of  some  male  organs  ; and  if  we  go  so  far  as  to  admit 
this,  we  must  further  allow  the  present  to  be  an  instance  of  herma- 
phroditism, in  which  one  of  the  sets  of  sexual  organs  was  capable  of 
assuming  its  appropriate  physiological  part  in  the  process  of  repro- 
duction, though  perhaps  unable,  if  we  may  judge  from  abortion 
liaviug  twice  occurred,  of  ultimately  perfecting  that  process. 

The  preceding  remarks  upon  the  functional  reproductive  powers 
of  reputed  true  hermaphrodites,  have  been  meant  to  apply  only  to 
the  supposed  perfection  of  one  order  of  their  sexual  organs.  It  be- 
comes a still  more  interesting  question  whether  it  ever  occurs  that 
in  any  abnormal  hermaphrodite  among  the  more  perfect  tribes  of 
animals,  both  kinds  of  sexual  parts  may  be  found  in  so  perfectly 
developed  a state  as  to  enable  the  individual  to  complete  the  sexual  • 
act  within  its  own  body,  or,  in  other  words,  to  impregnate  and  be 
impregnated  by  itself.  Though  we  have  assuredly  no  positive  proof 
to  furnish,*  that  a hermaphrodite  so  physiologically  perfect  has  ever 

- We  do  not  certainly  feel  entitled  to  place  among  the  category  of  correct  ob- 
servations either  the  alleged  case  given  by  Linnreus  (Mangetus’  Bibliotheca 
Chirurg.^  lib.  iv.)  of  a sow  with  perfect  male  organs  on  one  side,  and  a womb  con- 
taining several  foetuses  on  the  opposite ; or  that  mentioned  by  Faber  (Hernandez’ 
Xov,  Plant.  Anim.  Mcxic.  Ilistor.  p.  547)  and  quoted  by  Haller  and  Rudoli)hi,  of 
the  co-existence,  in  a rat,  of  ovaries  and  a uterus  with  nine  foetuses,  along  with 
complete  male  organs. 


QUESTION  OF  SELF-IMPREGNATION. 


531 


yet  been  observed,  and  should  very  strongly  doubt  its  occurrence, 
from  the  almost  universal  imperfection,  in  an  anatomical  point  of 
view,  of  the  malformed  organs ; yet  we  have,  on  the  other  hand,  no 
very  rational  ground,  except  that  of  the  experience  of  all  observers 
up  to  the  present  date,  for  denying  entirely  and  unconditionally  the 
utter  possibility  of  it.  And,  perhaps,  we  should  look  upon  this  pos- 
sibility with  a less  degree  of  scepticism,  when  we  consider  that  a 
double  hermaphroditism  exists  as  the  normal  sexual  condition  of 
some  of  the  lower  tribes  of  animated  beings  ; and,  at  the  same  time, 
take  into  account  the  fact  of  the  more  or  less  direct  communication 
which  has  been  generally  found  to  exist  between  the  female  uterus 
and  the  male  passages,  in  cases  of  lateral  and  of  complex  herma- 
phroditism, in  the  human  subject  and  in  quadrupeds. 

In  one  of  the  cases  of  hermaphroditism  in  the  goat,  previously 
quoted  from  Mayer,  and  where  there  were  present  two  male  testicles, 
epididymes,  vasa  deferentia,  and  vesicula3  seminales,  and  a female 
vagina,  uterus,  and  Fallopian  tubes,  with  a body  at  the  abdominal 
extremity  of  one  of  these  tubes,  that  was  supposed  by  Mayer  to 
resemble  a collection  of  Graafian  vesicles ; the  male  vasa  deferentia 
opened  into  the  female  vagina,  and  its  cavity,  with  that  of  the 
uterus  and  of  all  the  male  sexual  canals,  Avas  distended  Avith  a 
Avhitish  fluid  of  the  odour  and  colour  of  male  semen,  and  containing, 
according  to  Bergman,  the  chemical  principle  proper  to  that  secre- 
tion. It  is  not,  therefore,  altogether  Avithout  some  appearance  of 
foundation  in  fact,  that  Mayer  has  added  to  the  history  of  this  case 
the  folloAving  problematical  remark  : “Fuit  ergo  revera  hermaphro- 
ditus  semetipsum  foecundare  studens.”  ‘ 

In  a similar  strain,  Dr.  Harlan  has  added  to  the  account  that 
he  has  given  of  the  A^ery  complete  case  of  hermaphroditism,  already 
mentioned  as  met  Avith  in  the  Borneo  orang-outang,  the  folloAving 
observations  and  queries.  “ Admitting,”  he  remarks,  ‘‘  Avhat  in 
reality  appeared  to'  be  the  fact,  that  all  the  essential  organs  of  both 
sexes  Avere  present  in  this  individual,  had  the  subject  lived  to  adult 
age  most  interesting  results  might  have  been  elicited.  Could  not 
the  animal  have  been  impregnated  by  a male  individual,  by  ruptur- 
ing the  membrane  closing  the  vulva  ? or  by  masturbation,  might  not 
the  animal  have  impregnated  itself?  by  this  means  exciting  the  tes- 
ticles to  discharge  their  seminal  liquor  into  its  OAvn  vagina.  The 
imperfection  of  the  urethra  most  probably  Avould  have  preA^ented 
the  animal  from  ejecting  the  semen  into  the  vagina  of  another  indi- 
vidual.” ^ 

1 leones,  etc.,  p.  20,  ^ Medical  and  Physical  Pcsearches,  pp.  23,  24. 


532 


HERMAPHRODITISM. 


It  has  been  sometimes  urged  as  an  argument  conclusively  illus- 
trative of  the  fact  of  a double  hermaphrodite  impregnating  itself, 
that  in  the  hermaphrodite  Gastrojyhaga  gjini  described  by  Scopoli,* 
the  insect  is  stated  to  have  been  seen  to  advance  its  penis  and  copu- 
late with  its  own  female  organs ; and,  afterwards,  we  are  informed, 
the  female  side  laid  eggs  from  which  young  caterpillars  were  pro- 
duced. Before,  however,  admitting  this  case  to  present  an  incon- 
trovertible instance  of  absolute  hermaphroditism,  with  the  functions 
of  the  two  sets  of  sexual  organs  existing  in  a perfect  condition  upon 
the  same  individual,  it  is  necessary  to  recollect  a possible  source  of 
fallacy  in  this  circumstance,  that  female  Gastrophagae  have  been 
observed  to  lay  fertile  eggs,  although  they  had  not  had  previously 
any  connection  with  the  male,  as  remarked  by  Professor  Baster'  in 
one  instance  in  a female  Gastrophaga  quercifolia,  and  in  another  in 
the  Gastrophaga  pini  by  Suckow.®  The  same  fact  is  further  alleged 
to  have  been  observed  in  some  few  instances  by  Pallas,  Trevira- 
nus,  Bernouilli,  and  others,^  in  regard  to  individuals  belonging  to 
some  other  of'  the  higher  orders  of  insects  and  animals,  as  in  the 
Limnceus  auriciilaris^  and  Helix  vivipara^  among  Mollusca,  thus 
bringing  them  in  this  respect  into  analogy  with  the  Aphides  and 
•Cyprides. 

CAUSES  OF  HERMAPHRODITIC  MALFORMATION. 

As  yet  we  possess  very  little  accurate  knowledge,  either  in 
respect  to  the  mode  in  which  the  determining  causes  of  hermaphro- 
ditic malformation  act,  or  the  nature  of  these  causes  themselves. 
Upon  the  question  of  the  probable  or  possible  origin  of  actual  her- 
maphroditic or  sexual  duplicity,  Ave  have  offered  already  one  or  two 
remarks  at  pp.  313  and  315. 

Most  of  the  varieties  of  spurious  hermaphroditism  may,  as  Ave 
have  just  explained,  be  traced  to  an  arrest  in  the  development  of 
the  sexual  organs  at  one  or  other  period  of  their  eA^olution.  in  con- 
sequence of  Avhich,  some  of  those  types  of  structure  in  these  parts 
Avhich  Avere  intended  to  be  temporary  and  transitory  only,  are 
rendered  fixed  or  permanent  in  their  character.  Our  knoAvledge  of 

^ Tntrod;  ad  Hist.  Nat.  p.  416. 

2 Mem.  dc  V Acad.  Roy.  de  Berlin,  1772. 

3 Heusinger’s  Zcitschrift  fur  Organ.  Phys.,  Bd.  ii.  s.  263. 

* Burmeister’s  Entomology,  s.  204  ; Burdacli’s  Physiologic,  tom  i.  §§  44,  48. 

^ Isis  for  1817,  p.  320.  Spallanzani,  Mem.  sur  la  Rcsp.  p.  268. 


MORBID  INFLUENCES  OF  TESTES,  ETC. 


533 


the  more  immediate  causes  of  such  arrested  development  in  these 
and  in  other  individual  parts  and  organs  of  the  body  is  as  yet  ex- 
tremely limited.^  We  may,  however,  in  reference  to  the  particular 
forms  of  arrested  development  observed  in  hermaphroditism,  remark, 
that  in  consequence  of  the  great  influence  which,  as  we  have  already 
pointed  out,  is  exercised  by  morbid  states  of  the  ovaries  and  tes- 
ticles, in  retarding  or  preventing  the  evolution  of  the  sexual  appa- 
ratus and  characters  after  birth,  it  has  been  suggested  with  con- 
siderable probability  by  Meckel  ^ and  Isidore  St.  Hilaire,^  that,  in 
their  ultimate  analysis,  certain  cases  of  hermaphroditic  malformation 
may  be  traced  in  the  course  of  their  causation  to  morbid  influences 
exercised  in  the  early  embryo,  at  a period  more  or  less  near  to  con- 
ception, upon  the  ovaries  or  testicles,  or  upon  those  organs  of  a 
neuter  or  yet  undetermined  sex  which  afterwards  assume  the  struc- 
ture of  one  or  other  of  these  bodies.  Further,  the  effects  which 
this  supposed  morbid  influence  exercises  directly  upon  the  em- 
bryonic ovaries  and  testicles,  and  indirectly  through  them  upon  the 
rest  of  the  genital  apparatus,  and  consequently  the  modifications  of 
sexual  structure  which  it  produces,  may  possibly  be  much  varied 
according  to  its  extent,  duration,  and  nature,  and  according  to  the 
particular  period  of  development  at  which  it  comes  into  action.  It 
is  evident  that  this  explanation  of  hermaphroditism  can  only  refer 
to  the  varieties  of  the  malformation  which  consist  of  an  imperfec- 
tion or  deficiency  in  the  development,  and  cannot  apply  to  those 
instances  in  which  there  is  a superaddition  of  sexual  organs.  If, 
however,  we  can  once  satisfy  ourselves  that  any  set  of  cases  what- 
ever are  traceable  to  a morbid  action  affecting  the  testicles  or  ovaries 
of  the  early  embryo,  our  investigations  into  the  causes  of  these  cases 
will  necessarily  be  much  simplified,  for  our  inquiries  would  be  re- 
duced from  a vague  and  indefinite  search  after  the  production  of  a 
number  of  anomalies  of  structure  affecting  several  different  organs  at 
the  same  time,  to  an  attempt  to  trace  out  the  nature  of  those  morbid 
conditions  to  which  the  embryonic  testicles  and  ovaries  were  subject, 
and  which  were  capable  of  so  far  changing  the  structure  and  action 
of  these  organs  as  to  give  rise  to  the  effects  in  question.  Of  the 
diseased  states,  however,  to  which  the  reproductive  and  other  organs 
of  the  system  are  liable  during  the  progress  of  their  early  develop- 
ment, we  at  present  know  little  or  nothing,  although  in  the  investi- 

1 See  Cyclop,  of  Anat.  and  Thy s..  Art.  “Monstrosities.” 

2 Anat.Gen.,  tom.  1.  p.  609.- 
* Hist,  des  Anomal.  de  VOrganiz.,  tom.  ii.  58. 


534 


HERMxVPHRODlTISM. 


gation  of  this  subject,  a key,  we  believe,  may  possibly  be  yet  found 
to  the  explanation  of  many  of  those  malformations  to  which  different 
parts  of  the  body  are  subject. 

Osiander‘  and  Duges^  have  suggested  that  the  variety  of  spurious 
hermaphroditism  which  consists  of  a division  of  the  perineum  in  the 
male,  may  be  produced  mechanically  in  the  embryo  by  the  preter- 
natural accumulation  of  fluid  in  the  urinary  canal,  from  an  imper- 
forate state  of  the  uretlira,  and  the  consequent  distension  and  ultimate 
rupture  of  the  urethra,  etc.  From  cases  published  by  Sandifort, 
Howship,  Billard,  and  many  others,  we  are  now  fully  aware  of  the 
fact  that  all  the  urinary  canals  of  the  foetus  in  utero  are  occasionally 
found  morbidly  distended  with  a fluid,  which,  according  to  the  in- 
teresting observations  of  Dr.  Robert  Lee,®  would  appear  to  possess 
the  more  characteristic  qualities  of  urine.  We  have  dissected  one 
case  in  which  the  dilated  foetal  bladder  was  as  large  as  an  orange, 
and  have  seen,  in  the  Anatomical  Museum  of  Dr.  William  Hunter  at 
Glasgow,  the  preparation  of  another  instance  in  which  the  bladder 
of  a full-grown  foetus  was  dilated  to  the  size  of  that  of  the  adult 
subject.  In  one  case,  mentioned  by  Dr.  Merriman,  the  distended 
organ  contained  half-a-pint  of  urine  and  in  another,  detailed  by 
Mr.  Fearn,  it  was  capable  of  containing  as  much  as  two  quarts  of 
fluid.® 

It  is  not  impossible  that  the  causes  in  question — namely,  the 
obliteration  of  the  urethra  and  the  consequent  distension  of  all  the 
urinary  passages,  and  probably  also  of  the  sexual  canals  communi- 
cating with  these  passages — may  occasionally  produce  in  the  male 
embryo  a re-opening  of  the  perineal  fissure,  giving  thus  to  the 
external  parts  the  appearance  of  a female  vulva,  and  perhaps  at  the 
same  time  may  lead  to  the  retention  and  imperfect  development  of 
the  testicles  by  the  distension  of  their  ducts,  and  the  unusual  com- 
pression to  which  these  organs  may  be  subjected.  Indeed,  we  have 
satisfactory  evidence,  in  a few  instances,  that  such  a cause  may  have 
been  in  operation,  by  our  detecting  the  other  acknowledged  effects 
of  the  urinary  accumulation  in  question — such  as  preternaturally 
dilated  ureters,  and  a cystic  form  of  the  infundibula  of  the  kidneys, 
as  in  a case  of  hermaphroditism  given  by  Mayer,  in  the  human 

1 Ncuc  Denkw.  fiir  Acrtzte  und  Gchurtsh.,  Bd.  i.  pp.  264-267. 

2 Ejjhem.  Med.  de  Montpellier,  tom.  v.  pp.  17,  45,  and  52. 

^ London  Med.-Chirurg.  Trans.,  vol.  xix. 

^ London  Med.  and  Flips.  Journ.,  vol.  xxv.  p.  279. 

® Lancet  for  1834-35,  p.  178. 


IIEUEDITAllY  HYPOSPADIAS. 


535 


foetus/  in  the  kid  described  by  Haller/  and  in  the  child  whose  case 
we  have  already  quoted  from  Steghlener.  (See  p.  4G6.) 

At  the  same  time,  the  total  absence  of  these  collateral  proofs  in 
most  other  cases  of  hypospadias,  our  knowledge  of  the  fact  that  the 
perineal  aperture  is  in  some  cases  never  shut,  and  the  difficulty  of 
conceiving  the  possibility  of  its  being  re-opened  when  once  it  is 
firmly  closed,  are  perhaps  sufficient  to  show  that  the  cause  or  causes 
alluded  to  produce  in  but  few  if  any  instances  the  effect  here  attri- 
buted to  them. 

We  deem  it  not  uninteresting  to  point  out  in  this  place,  under 
the  question  of  the  origin  of  hermaphroditic  malformations,  a cir- 
cumstance which  has  struck  us  in  considering  one  or  two  of  the 
cases  in  which  the  sexual  apparatus  of  one  side  of  the  body  was 
more  imperfectly  developed  than  that  of  the  other — viz.  that  the 
opposite  side  of  the  encephalon  was  at  the  same  time  defectively 
formed.  Thus  in  the  case  of  Charles  Durge,  on  the  right  side  of  whose 
body  there  was  a well-formed  testicle,  and  on  the  left  an  imperfect 
ovary,  the  right  hemispheres  of  the  cerebrum  and  cerebellum,  but 
particularly  of  the  latter,  were  found  by  Professor  Mayer  to  be 
smaller  and  less  developed  than  the  left,  and  the  left  side  of  the 
occiput  was  externally  more  prominent  than  the  right.  The  same 
author,  in  the  account  of  his  case  of  hermaphroditism  in  a person 
eighteen  years  of  age,  which  we  have  previously  quoted,*  and  where 
there  was  an  imperfect  testicle,  etc.,  on  the  right  side,  but  no  trace 
of  testicle  or  ovary  on  the  left,  incidentally  mentions  that  the  right 
side  of  the  cranium  was  somewhat  prominent — “ dextra  pars  cranii 
paullulo  prominet,”  in  correspondence,  there  is  every  reason  to 
believe,  with  a slight  predominance  in  size  in  the  hemispheres  of 
the  encephalon  of  the  same  side.  In  adducing  these  two  cases,  we 
do  not  wish  to  draw  any  inference  with  regard  to  the  relation  of 
causation  between  the  size  and  development  of  the  encephalic  mass 
and  the  determination  of  the  sex,  but  would  merely  point  out  the 
facts  themselves  in  the  meantime,  for  the  purpose  of  drawing  atten- 
tion to  the  subject  in  the  observation  of  any  future  similar  instances 
that  may  happen  tct  occur. 

In  connection  with  the  question  of  the  causes  of  hermaphroditism, 
it  is  interesting  to  remark  that  in  some  instances  malformations  of 
the  genital  organs,  giving  rise  to  appearances  of  hermaphroditism, 
have  been  observed  to  be  hereditary  in  particular  families,  both  on  the 

^ See  p.  8 of  leones^  etc.  ^ Comment.  Soc.  Reg.  Sc.,  Getting.,  tom.  i.  p.  2. 

^ leones,  p.  12. 


90 


536 


HERMAPHRODITISM. 


maternal  and  paternal  sides  ; and  in  other  cases  to  occur  among 
several  of  the  children  of  the  same  parents.  Thus  Heuremanni 
mentions  an  example  of  a family,  the  females  of  which  had  for 
several  generations  given  birth  to  males  who  were  all  affected  with 
hypospadias  ; and  Lecat  * alleges  that  a degree  of  hypospadias  is  not 
uncommon  among  families  in  Normandy.  In  Eust’s  Magazin  an  in- 
stance is  related  of  a degree  of  hypospadias  existing  in  a father  and 
son.^  Baum,"^  in  his  essay  on  congenital  fissures  of  the  urethra,  has 
referred  to  two  instances  of  the  existence  of  hypospadias  in  brothers 
of  the  same  family,  the  first  mentioned  by  Walrecht,^  and  the  second 
by  Gockel,®  Sir  Everard  Home  ^ found  two  cases  of  hypospadias  in 
two  children  belonging  to  the  same  parents.  Kauw  Boerhaave®  men- 
tions an  example  of  four  hypospadiac  brothers,  and  Lepechin  another 
instance  of  three.®  Naegele  has  reported  a case  in  which  two  male 
twins  were  both  hypospadiac  ; and  Katsky  and  Saviard^^  have 
mentioned  similar  instances. 

When  treating  of  transverse  hermaphroditism,  we  have  already 
alluded  to  another  fact  long  and  extensively  known  among  our 
agriculturists,  but  first  prominently  brought  before  the  notice  of 
physiologists  by  Mr.  Hunter,  that  the  free-martin  cow,  or  the  cow  that 
is  born  co-twin  with  a male,  is  generally  barren,  and  has  its  sexual  or- 
gans more  or  less  defectively  developed  or  hermaphroditically  formed.** 
In  three  different  instances  Mr.  Hunter  confirmed  the  fact  of  the 
anomalous  sexual  development  of  such  animals  by  dissection ; and 
Scarpa*^  and  Gurlt**  have  published  some  additional  observations 
and  cases.  We  have  lately  had  an  opportunity  of  dissecting  the 
sexual  parts  of  two  adult  free-martins,  and  found  them,  as  already 
detailed,  formed  after  an  abnormal  and  imperfect  sexual  type  ; and 
our  friend  Dr.  Allen  Thomson  made  some  years  ago  a similar  obser- 
vation upon  a free-martin  twin  foetal  calf.  Cases,  however,  excep- 
tional to  the  general  fact  of  the  sterility  and  imperfect  sexual  con- 
formation of  the  free-martin  twin  cow  are  not  unfrequently  met 

^ J/ed.  Bebhaclit.  Bel.  ii.  s.  234 ; and  Laroche,  Sur  les  Monstrosites  de  la  Face, 
p.  30.  ‘ 

2 Arnaud,  loc.  cit.  p.  312.  ^Magazin  fur  die  Gesaminie  Heilkunde,  Bd.  xviii. 
s.  113.  De  fissuris  urethrae  virilis  congenitis,  p.  54. 

® Burdach’s  Metamorphose  dcs  Geschlechter,  p.  52. 

® Ejdi.  Nat.  Cur.  Dec.  ii.  aim.  5,  1686,  p.  85.  Comp.  Anat.  iii.  p.  320. 

® Nov.  Com.  Acad.  Sc.  Pctropolit.  tom.  i.  p.  61,  tab.  xi. 

Ibid.  tom.  xvi.  p.  525.  Meckel’s  Archiv,  Bd.  v.  s.  136. 

Acta  M.  Berol.  Dec.  1,  tom.  ix.  p.  61.  Observ.  Chirurg.  p.  284. 

See  also  vol.  i.  p.  315.  Mem.  della  Societa  Italiana,  tom.  ii.  p.  846. 

Lehrbuch  der  Pathol.  Anat.  Bd.  ii.  s.  188. 


SEXUAL  MALFOIIMATION  IN  TWINS. 


537 


with.  Mr.  Hunter  found  the  sexual  organs  of  a free-martin  calf, 
that  died  when  about  a month  old,  apparently  naturally  constituted. 
He  speaks  also  of  having  heard  of  some  free-martins  that  were  so 
perfectly  formed  in  their  sexual  parts  as  to  be  capable  of  breeding ; 
and  different  instances  of  their  fecundity  have  been  published  by 
Dr.  Moulson  and  others*  since  the  time  that  Mr.  Hunter  directed 
attention  to  this  subject.  In  some  pretty  extensive  inquiries  whicli 
we  have  made  in  regard  to  this  point  among  the  agriculturists  of 
the  Lothians,  we  have  learned  only  of  two  instances  in  which  free- 
martins  proved  capable  of  propagating,  and  such  cases  seem  to  be 
always  looked  upon  as  forming  exceptions  to  the  general  rule. 

We  are  not  aware  that  among  other  uniparous  domestic  animals, 
as  the  goat,  mare,  etc.,  when  a female  is  born  co-twin  with  a male, 
this  female  is  sterile,  and  has  its  sexual  organs  hermaphroditically 
formed,  as  in  the  free-martin  cow ; and  we  are  sufficiently  assured 
that  no  such  law  holds  with  regard  to  twins  of  opposite  sexes 
among  sheep.  Sir  Everard  Home,  in  his  essay  on  monstrous  forma- 
tions,^ mentions  that,  in  warm  countries,  nurses  and  mid  wives  have 
a prejudice  that  such  women  as  have  been  born  twins  with  males 
seldom  breed ; and  we  have  found  the  same  prejudice  existing  to  a 
considerable  degree  among  the  lower  orders  in  Scotland.  Mr.  Cribb  ^ 
of  Cambridge  published  in  1823  a short  paper  in  order  to  refute 
this  notion  so  far  as  regarded  the  human  subject.  He  refers  to  the 
histories  of  seven  women  who  had  been  born  co-twin  with  males. 
Six  of  these  had  children,  and  the  remaining  seventh  subject  alone 
had  been  married  for  several  years  without  any  issue.  We  have 
ourselves  made  a series  of  extensive  inquiries  of  the  same  nature  as 
those  published  by  Mr.  Cribb,  and  have  obtained  authentic  informa- 
tion regarding  42  adult  married  females  who  had  been  born  as 
twins  with  males.  Of  these  36  were  mothers  of  families,  and  6 had 
no  children,  though  all  of  them  had  been  married  for  a number  of 
years.  Two  of  the  females  who  have  himilies  were  each  born  as  a 
triplet  with  two  males.  In  the  Medical  Repository  for  1827,  an 
anonymous  author  has  mentioned  an  instance  of  quadruplets  con- 
sisting of  three  boys  and  a girl,  wdio  were  all  reared.  The  female 
afterwards  became  herself  the  mother  of  triplets.  Limited  as  the 
data  to  which  we  here  allude  confessedly  are,  they  are  still  amply 
sufficient  to  show  that  in  by  far  the  majority  of  cases  the  females  of 

^ Loudon’s  Magazine  of  Natural  History,  vol.  v.  p.  765.  See  also  Youatt  on 
Cattle,  p.  539,  Farmer  s Magazine  for  Nov.  1806  and  Nov.  1807. 

" Oomp.  Anat.  vol.  iii.  pp.  33-34.  ^ London  Med.  Repos,  vol.  xx.  p.  213. 


538 


HERMAPHRODITISM. 


twins  of  opposite  sexes  are  in  the  human  subject  actually  fertile, 
and,  as  some  of  the  cases  we  have  collected  show,  they  are  occasion- 
ally unusually  prolific. 

As  to  the  cause  of  the  malformation  and  consequent  infecuiidity 
of  the  organs  of  generation  in  the  free-martin  cow,  we  will  not 
venture  to  offer  any  conjecture  in  explanation  of  it.  It  appears  to 
us  to  be  one  of  the  strangest  facts  in  the  whole  range  of  teratological 
science,  that  the  twin  existence  in  utero  of  a male  along  with  a female 
should  entail  upon  the  latter  so  great  a degree  of  malformation  in  its 
sexual  organs,  and  in  its  sexual  organs  only.  The  circumstance  becomes 
only  the  more  inexplicable  when  we  consider  this  physiological  law 
to  be  confined  principally  or  entirely  to  the  cow,  and  certainly  not 
to  hold  with  regard  to  sheep,  or  perhaps  any  other  uniparous  animal. 

The  curiosity  of  the  fact  also  becomes  heightened  and  increased 
when  we  recollect  that  when  the  cow  or  any  other  uniparous  animal 
has  both  twins  of  the  same  sex,  as  two  males  or  two  females,  these 
animals  are  always  both  perfectly  formed  in  their  sexual  organisation, 
and  both  capable  of  propagating.  In  the  course  of  making  the  pre- 
ceding inquiries  for  females  born  co-twin  with  males  in  the  human 
subject,  we  have  had  a very  great  number  of  cases  of  purely  female 
and  purely  male  twins  mentioned  to  us,  who  had  grown  up  and 
become  married,  and  in  only  two  or  three  instances  at  most  have  we 
heard  of  an  unproductive  marriage  am.ong  such  persons. 

Further,  we  may,  in  conclusion,  remark  that  among  the  long 
list  of  individual  cases  of  hermaphroditism  in  the  human  subject 
that  we  have  jmd  occasion  to  cite,  we  find  only  one  instance  ^ in 
which  the  malformed  being  is  stated  to  have  been  a twin.  Katsky, 
however,  Naegele,  and  Saviard,  have  each,  as  before  stated,  mentioned 
a case  in  which  both  twins  were  hermaphroditically  formed  in  their 
sexual  organs. 

HERMAPHRODITISM  IN  DOUBLE  MONSTERS. 

One  of  the  most  curious  facts  in  the  history  of  double  monsters 
is  the  great  rarity  of  an  opposite  or  hermaphroditic  sexual  type  in 
their  two  component  bodies,  the  genital  organs  of  both  bodies  being 
almost  always  either  both  female  or  both  male. 

Physiological  science  affords  us  at  present  no  satisfactory  clue  to 
the  explanation  of  this  singular  circumstance.  From  two  cases  of 
double  monstrous  embryos  observed  in  the  egg  of  the  domestic  fowl 

^ Eschriclit’s  case  of  transverse  hermapliroditism,  see  p.  455. 


SEX  OF  DOUBLE  MONSTERS. 


539 


by  Wolff  1 and  Baer, 2 and  from  a similar  case  met  with  in  the  egg  of 
the  goose  by  Dr.  Allen  Thomson,  it  appears  certain  that  double 
monsters  originate  upon  a single  yolk,  probably  in  consequence  of 
the  existence  of  two  cicatriculse,  more  or  less  complete,  or  of  two 
germdnal  points,  upon  a single  germinal  vesicle,  or  of  two  germinal 
vesicles  upon  a single  yolk.^  In  such  a case  the  two  bodies  of  the 
double  monster  are  so  early  and  intimately  united  together  as  to 
form,  almost  from  the  commencement  of  development,  a single 
system ; and  therefore  the  fact  of  the  uniformity  of  their  sexual 
character  is  the  less  remarkable. 

The  fact  itself,  however  we  may  explain  it,  of  the  comparatively 
extreme  rarity  of  both  male  and  female  sexual  organs  upon  double 
monsters  seems  sufficiently  established  by  various  careful  investi- 
gations made  into  the  subject.  Thus,  out  of  forty-two  perfectly 
double  monsters  which  Haller*  was  able  to  collect  at  the  time  at 
which  he  wrote,  there  were  only  two  that  were  supposed  to  be  of 
double  sex,  or,  in  other  words,  that  had  one  body  male  and  the 
other  female.  Among  double-headed  monsters  with  single  lower 
extremities,  he  found  a hermaphroditic  type  more  common,  and 
adduces  three  examples  of  it. 

In  re-investigating  this  matter,  the  late  Professor  Meckel*  could 
discover  among  the  numerous  class  of  monsters  with  perfectly 
double  bodies,  united  anteriorly  or  laterally  by  the  thorax  and 
abdomen,  only  one  very  doubtful  case  of  exception  to  the  above 
general  fact.  In  the  class  of  double  monsters  united  in  the  region 
of  the  pelvis,  he  mentions  two  exceptional  cases  from  Valentin  * 
and  Hasenest  / of  double-headed  monsters  with  single  bodies  he 
quotes  three  similar  cases  from  Lemery,*  Bacher,®  and  Bilsius  and 
of  monsters  with  a single  head  and  double  body  he  adduces  two 
cases  from  Brissseus^^  and  Condamine  in  which,  in  a like  manner, 
one ‘body  of  the  monster  was  supposed  to  have  female  and  the 

^ Nov.  Comment.  Acad.  Peiropolit.  tom.  xiv.  p.  456. 

2 Meckel’s  Archiv  fiir  Physiologie,  etc.,  for  1827,  p.  576. 

2 We  have  in  our  possession  a preparation  from  a duck’s  egg,  in  which  two 
full-gi-own  foetuses  are  developed  on  opposite  sides  of  a single  yolk  of  the  common 
size. 

^ Opusc.  Anai.  1751,  p.  176.  ® De  DiipUcitate  Monstrosd,  p.  21. 

® Eph.  Nat.  Cur.  Dec.  ii.  ann.  iii.  p.  190. 

^ Comment.  Lit.  Norimb.  1743,  p.  58. 

® Mem.  de  V Acad,  dcs  Sc.  de  Paris,  for  1724. 

^ Roux'  Jour,  de  Med.  1788,  p.  483.  Blankaart’s  Coll.  Med.  etc.,  1680. 

Six  Obscrvat.  de  M.  Brisscau:  Paris,  1734,  p.  33. 

^2  Mem  de  V Acad,  des  Sc.  1733,  p.  401. 


540 


HERMAPHRODITISM. 


other  male  sexual  organs.  Several  of  these  cases,  however,  cer- 
tainly rest  upon  too  doubtful  authority  and  insufficient  observation. 

Isidore  St.  Hilaire  has  still  farther  extended  the  data  on  which 
the  above  general  fact  is  founded,  by  showing  that  the  same  unifor- 
mity of  sex  holds  good  with  respect  to  double  parasitical  monsters,^ 
and  even  in  monstrosities  double  by  inclusion.  Thus,  out  of  this 
last  interesting  class  of  double  monsters,  he  alludes^  to  ten  distinct 
cases  in  which  the  sex  of  the  included  being  was  ascertained.  In 
six  out  of  these  ten  cases  the  including  and  included  body  were 
both  male ; and  in  the  other  four  they  were  both  female. 

On  the  whole,  therefore,  we  must  consider  as  founded  on  a 
proper  induction  from  the  existing  data,  the  axiom  of  Meckel, — 
“ Sexuum  diversorum  indicia  in  eodem  organismo,  quantumvis  dup- 
licitate  peccet,  non  dari,  sed  unum  tantum  observari.”*  But  while  all 
the  data  hitherto  collected  with  regard  to  this  subject  would  seem 
thus  to  point  it  out  as  one  of  the  most  constant  and  best  ascer- 
tained laws  in  teratology,  still  we  are  not  altogether  disposed  to 
consider  it,  with  Zeviani^  and  Lesauvage,®  as  subject  to  no  excep- 
tions whatever.  In  the  study  of  monstrosities,  as  in  the  study  of 
other  departments  of  medical  science,  we  find  many  general,  but  no 
universal  laws. 


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541 


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* lichen  Zwitterhildung,  etc.  ; Ahhand.  der  Kdnigl.  Akad.  der  Wissens. 
zu  Berlin  fur  1825  : Berk  1828.  Lippi,  Dissert.  Anatomico-Zooto- 
mico-Fisiologiche,  etc.  : Firenze,  1826.  Duges,  Mdm.  sur  llierma- 
phrodisme,  in  Epliemerides  MSdicales  de  Montpellier,  tom.  i. : Mont. 
1827.  Knox,  Outline  of  a theory  of  hermaphrodism,  in  Brewster's 
Edinburgh  Journal  of  Science,  vol.  ii.  p.  322  : Edinb.  1830.  Muller, 
Bildungsgeschichte  der  Genitalien:  Dusseldorf,  1830.  Gurlt,  Lehrh. 
der  Patholog.  Anal,  der  Hates- Sdugethiere,  Bd.  ii. : Berlin,  1831. 
Mayer,  leones  Seleclce  prmparat.  Musei  Anatom.  Bonnensis ; Dccas  Her- 
maphroditorum,  p.  8 : Bonn.  1831  ; and  Walther's  and  Graefe's 
Journal,  etc.,  Bd.  xvii.  Beatty,  Article  Doubtful  Sex,  in  Cyclopcedia 
of  Bract.  Med.:  London,  1833.  Beck,  Medical  Jurisprudence,  chap, 
iv.  pp.  69-81,  Doubtful  Sex:  London,  1836.  Isidore  St.  Hilaire, 
Ilistoire  des  Anomalies  de  V Organization,  etc.:  Paris,  1836.-  Barry, 
On  the  Unity  of  Structure  in  the  Animal  Kingdom,  and  in  Jameson's 
Edinb.  New  Philos.  Journ.  for  April  1837.  See  also  the  references 
in  the  footnotes. 


PROPOSAL  TO  STAMP  OUT  SMALL-POX 

AND  OTHER  CONTAGIOUS  DISEASES. 


In  despite  of  the  marvellous  protective  influence  of  vaccination, 
the  mortality  produced  by  small-pox  in  Great  Britain  is  still  very 
great  and  startling.  Like  other  contagious  maladies  it  varies  much 
in  the  number  of  its  victims  from  one  year  to  another ; yet,  during 
the  ten  years  from  1856  to  1865,  small-pox  destroyed  in  this 
island  51,034  individuals.  In  one  of  the  last  of  these  years,  1863, 
not  less  than  7610  died  from  it ; and  in  1864  its  amount  of  mor- 
tality reached  to  9425. 

Such  figures  as  these  numerals  denote  scarcely  convey  to  the 
mind  an  adequate  idea  of  the  deplorable  loss  of  life  still  resulting 
among  us  from  the  ravages  of  this  one  malady  ; the  more  so  as  the 
mortality  from  the  disease  is  distributed  through  the  whole  scattered 
population  of  the  island.  But  (to  state  it  otherwise)  if  in  any  one 
year  some  overwhelming  catastrophe  destroyed  all  the  living  popu- 
lation of  the  counties  of  Nairn  or  Kinross ; or  swept  away  every 
living  inhabitant  of  the  cathedral  cities  of  Lichfield,  Bipon,  or  Wells  ; 
or  slaughtered  four  or  five  regiments  of  soldiers ; or  smothered  as 
many  as  five  or  six  times  the  number  of  members  of  the  House  of 
Commons — such  an  event  would  assuredly  appal  and  terrify  the 
public  and  its  guardians ; and  the  strongest  measures  would,  no 
doubt,  be  called  for,  with  the  view  of  preventing  the  recurrence  of 
the  catastrophe,  provided  its  prevention  were  at  all  possible.  Is 
•the  similar  amount  of  human  slaughter  to  which  our  population  is 
constantly  subject  by  small-pox — not  once,  but  continuously;  not 
one  year,  but  each  year — preventible  1 I believe  that  it  is  so  ; and 
I believe  further  that  the  hygienic  measures  required  for  effecting 
this  prevention  would  be  found  neither  specially  difficult  nor 
expensive  to  the  country,  while  they  would  save  annually  hundreds, 
if  not  thousands,  of  our  population  from  death,  by  a disease  which, 
even  when  it  spares  life,  too  often  leaves  permanent  lesions,  and  a 
broken  and  damaged  constitution. 

To  understand  the  means  to  which  I point,  let  it  be  premised 


544 


PROPOSAL  TO  STAMP  OUT  SMALL-POX,  ETC. 


that  small  pox  is — like  scarlet  fever,  measles,  and  hooping-cough — 
only  a species  of  disease  which,  as  a general  law,  attacks  once  in 
a lifetime,  and  is  only  propagated  from  an  infected  individual  to  a 
susceptible  individual,  by  a specific  poison  generated  in  the  course 
of  the  malady,  and  transmitted  from  the  affected  to  the  healthy ; 
first,  by  the  near  approach  of  the  one  to  the  other ; secondly,  by 
their  contact ; thirdly,  by  direct  inoculation ; or,  fourthly,  by 
fomites,  or  by  susceptible  individuals  being  exposed  to  the  virus 
when  it  has  been  imbibed  into  clothes,  etc.,  with  which  the  sick 
have  been  in  contact.  We  would  no  more  expect  this  known 
species  of  disease  or  poison  to  originate  de  novo  at  the  present  day, 
under  any  combination  of  circumstances,  than  we  would  expect  a 
known  species  of  animal  or  plant — as  a dog  or  a hawthorn — to 
spring  up,  de  novo,  and  without  antecedent  parentage. 

The  beneficiaf  influence  of  Dr.  Jenner’s  immortal  discovery 
saves  from  death  from  small-pox,  in  our  present  population  in  Great 
Britain,  probably  about  80,000  lives  yearly.  As  we  have  already 
stated,  however,  there  still  die  from  its  ravages  about  5000  annually. 
Some  among  these  5000  have  been  duly  vaccinated,  and  yet  are 
susceptible  of  small-pox  after  cow-pox,  just  as  men  formerly  were 
found  susceptible  of  a second  attack  of  small-pox  after  they  had 
passed  through  a previous  attack  of  natural  or  inoculated  small-pox. 
Others  seem  susceptible  in  consequence  of  the  vaccination  having 
been  performed  inadequately  with  imperfect  matter ; or  without 
leaving  vaccination-scars  of  sufficient  quality  or  quantity.  Again,  a 
large  class  of  those  that  perish  from  small-pox  consists  of  individuals 
who  have  never  been  vaccinated  at  all,  or  who  happen  to  be  exposed 
to  the  variolous  poison  antecedent  to  the  age  at  which  vaccination 
is  usually  performed.  Doubtlessly  a stricter  enforcement  of  the 
new  compulsory  laws  of  vaccination,  and  a greater  amount  of  atten- 
tion to  its  proper  performance  with  proper  matter,  will  betimes 
diminish  the  number  of  the  susceptible  class.  Yet,  in  the  mean- 
time, the  disease  still  revels  with  fatal  power  among  our  population  ; 
and  the  question  is.  Can  it  be  arrested  in  its  progress  ? 

The  public  mind  has,  during  the  last  two  or  three  years,  become 
familiarised  with  the  idea  of  “ stamjnng  out''  a disease,  in  the  instance 
of  Einderpest — a malady  apparently  spreading  in  this  country,  as 
small-pox  does,  by  contagion  only ; and  every  one  well  knows  the 
perfect  success  with  which  this  affection  has  been  lately  banished 
out  of  England,  while  it  has  also,  by  due  care,  been  prevented  spread- 
ing to  Ireland  and  the  Isle  of  Man.  I believe  the  same  princqde 


PUBLIC  HEALTH  ACT. 


545 


of  stamping  out  could  be  as  successfully  applied  to  the  extirpation 
of  small-pox  among  us  as  it  has  been  applied  to  the  extirpation  of 
rinderpest ; hut  of  course  with  great  differences.  The  rinderpest  has 
been  stamped  out  by  killing  all  the  animals  labouring  under  the 
disease ; and  in  many  instances  all  those  animals  of  the  same  flock 
which  had  been  exposed  to  the  contagion  of  it,  but  which  were  not 
yet  attacked  by  the  malady.  The  mission,  however,  of  the  human 
physician  is  ever  to  save  life,  never  to  destroy  it.  And  yet,  in 
accordance  with  this  leading  and  divine  principle,  we  could,  in  my 
opinion,  as  surely  and  as  swiftly  stamp  out  small-pox  as  rinderpest 
has  been  stamped  out.  For  all  that  appears  necessary  for  the  pur- 
pose is  simply  the  methodic  temporary  seclusion,  segregation,  or 
quarantine,  of  those  aflected  with  small-pox,  until  they  have  com- 
pletely passed  through  the  disease  and  lost  the  power  of  infecting 
and  injuring  others.  The  poleaxe  was  the  chief  and  leading  mea- 
sure required  to  stamp  out  rinderpest.  Isolation  is  the  chief  and 
leading  measure  required  to  stamp  out  small-pox. 

Various  rules  and  arrangements  would  be  necessary  to  effect  the 
requisite  amount  of  isolation.  Without  at  all  entering  into  details, 
let  me  here  observe  that  the  following  measures  would  perhaps  form 
the  chief  points  to  be  attended  to  in  the  way  of 

Regulations. 

1st.  The  earliest  possible  notification  of  the  disease  after  it  has  once  broken 
out  upon  any  individual  or  individuals. 

2d.  The  seclusion,  at  home  or  in  hospital,  of  those  affected,  during  the  whole 
progress  of  the  disease,  as  well  as  during  the  convalescence  from  it,  or 
until  all  power  of  infecting  others  is  past. 

3d  The  surrounding  of  the  sick  with  nurses  and  attendants  who  are  them- 
selves non-conductors  or  incapable  of  being  affected,  inasmuch  as  they 
are  known  to  be  protected  against  the  disease  by  having  already  passed 
through  cow-pox  or  small-pox. 

Ath.  The  due  purification,  during  and  after  the  disease,  by  water,  chlorine,  car- 
bolic acid,  sulphurous  acid,  etc.,  of  the  rooms,  beds,  clothes,  etc.,  used 
by  the  sick  and  their  attendants,  and  the  disinfection  of  their  own 
persons. 

Here,  as  elsewhere,  to  obtain  a great  public  good,  some  private 
or  individual  inconvenience  must  for  the  time  be  undergone  by 
those  who  unfortunately  become  the  subjects  of  the  disease.  But 
since  first  publicly  speaking  of  the  stamping  out  of  small-pox,  I find 
that  in  18G7  the  Legislature  has  passed  the  “Public  Health  Act” 
of  Scotland,  a most  excellent  measure,*  which  gives  some  of  the 

^ The  Public  Health  Act  for  Scotland  has  been  published  by  the  Messrs. 
Blackwood,  with  notes  by  Sheriff  Monro. 


546  PROPOSAL  TO  STAMP  OUT  SMALL-fOX,  ETC. 

leading  powers  required  to  enforce  a series  of  regulations  like  the 
preceding.  The  Sanitary  Act  of  1866  for  England  and  Ireland 
tends  in  the  same  direction,  but  is  not  so  comprehensive.  For  the 
“ general  prevention  and  mitigation”  of  infectious  diseases,  and  other 
purposes,  the  Scottish  Act  has  erected  a number  of  local  boards 
everywhere  throughout  Scotland,  consisting,  according  to  circum- 
stances, of  the  town-councils,  of  the  police-commissioners,  or  of  the 
parochial  boards.  These  “ local  authorities”  are  each  entrusted  with 
the  power  of  appointing  sanitary  inspectors  and  medical  officers 
under  them,  and  are  themselves  so  far  under  the  central  control  and 
advice  of  the  “ Board  of  Supervision.”  They  are  bound  to  provide 
district  hospitals  or  temporary  places  for  the  reception  of  the  sick ; 
to  remove  to  them,  by  suitable  carriages,  any  person  suffering  from 
contagious  or  infectious  disorders : in  case  of  need  to  direct  not 
the  sick  to  be  removed,  but  to  remove  all  other  unaffected  persons 
surrounding  them,  providing  suitable  accommodation  for  these 
unaffected  elsewhere ; and  to  have  in  each  district  all  necessary 
apparatus  and  attendants  for  the  disinfection  of  woollen  and  other 
articles,  clothing  or  bedding,  which  may  have  become  dangerous 
from  contact  with  diseased  individuals.  Such  powers  are  of  the 
highest  importance  for  the  protection  of  the  general  community 
against  small-pox  and  other  such  infectious  diseases  among  the 
poorer  classes  of  the  population  ; but  regulations  in  the  same  spirit 
would  equally  benefit  the  highest  and  richest  in  the  land,  both 
individually  and  collectively,  and  the  sick  as  well  as  the  uninfected ; 
the  necessary  amount  of  isolation  of  the  sick  being  of  course 
allowed,  to  all  who  wished  it  and  could  afford  it,  to  be  effected  at 
their  own  homes. 

The  Legislature  has  no  scruple  in  interfering  in  some  other 
diseases  to  as  great  or  indeed  to  a greater  extent.  It  enforces, 
for  instance,  the  isolation  of  any  individual  affected  with  insanity, 
be  he  rich  or  poor,  who  is  a homicidal  lunatic,  endangering  the  lives 
of  others.  If,  by  a law  which  no  one  thinks  harsh  or  severe, 
lunatics  are  prevented  from  destroying  the  lives  of  their  fellow- 
men,  why  should  it  be  thought  harsh  or  severe  that  people  affected 
with  small-pox  should  be  prevented  from  dealing  out  destruction 
and  death  to  all  the  susceptible  with  whom  they  happen  to  come  in 
contact Homicidal  lunatics  do  not  destroy  annually  in  Great 
Britain  above  eight  or  ten,  on  an  average,  of  their  fellow-men. 
Small-pox  patients  yearly  destroy,  on  the  contrary,  hundreds  instead 
of  units  of  their  fellow-men  in  this  island.  Sixty  years  ago,  when 


QUESTION  OF  ENFOECING  ISOLATION. 


547 


speaking  in  the  House  of  Commons  of  the  gross  iniquity  of 
inoculating  with  small-pox  the  out-patients  of  a London  hospital, 
and  then  allowing  these  inoculated  persons  to  infect  others  with  the 
disease,  Mr.  Sturges  Bourne  strongly  but  truly  remarked  : — “ I 
think  that  the  Legislature  would  be  as  much  justified  in  taking  a 
measure  to  prevent  this  evil  by  restraint,  as  a man  would  be  in 
snatching  a firebrand  out  of  the  hands  of  a maniac  just  as  he  was 
going  to  set  fire  to  a city.”  A rattlesnake  or  a tiger  escaping  from 
a travelling  menagerie  into  a school  full  of  children  would,  in  all 
probability,  not  wound  and  kill  nearly  so  many  of  these  children  as 
would  a boy  or  girl  coming  among  them  infected  with,  or  still 
imperfectly  recovered  from,  small-pox,  or  scarlet  fever,  or  measles,  or 
hooping-cough.  Most  properly  the  cobra  and  the  tiger — because 
they  are  always  dangerous — are  always,  as  far  as  possible,  prohibited 
from  making  such  visitations  ; and  the  infected  boy  or  girl  should 
be  prohibited  also,  during  the  time  that  they  are  dangerous,  by 
running  through  the  course  and  convalescence  of  such  contagious 
diseases ; or,  in  other  words,  while  they  exhale  from  their  bodies  a 
virus  of  disastrous  and  deadly  potency. 

The  great  object  of  preventing  the  diffusion  of  small-pox  in  any 
city,  or  village,  or  hamlet,  by  the  stamping-out  measures  which  I 
have  ventured  to  suggest  in  this  communication,  would  consist,  of 
course,  chiefly,  when  practicable,  in  isolating  the  very  first  cases. 
Some  time  ago  a professional  friend,  to  whom  I was  explaining 
these  views,  objected  to  them,  that  in  the  case  of  the  town  of  Leith, 
which  was  the  habitat  of  small-pox  in  1861  and  1862,  the  disease 
was  at  one  time  too  diffused  to  apply  them.  Dr.  Paterson  of  Leith, 
however,  has  kindly  informed  me  that  at  the  time  of  the  visitation 
of  the  malady  he  made  an  official  inquiry  into  its  origin,  and  found 
it  to  be  this : — “ A beggar  woman,  on  tramp  from  Newcastle, 
brought,  in  the  course  of  her  wanderings,  to  Leith,  a child  lately 
affected  with  small-pox,  and  with  the  crusts  of  the  eruption  upon  it. 
In  Leith  she  became  an  inmate  of  a lodging-house  in  a “ land  ” or 
block  of  buildings  full  of  lodgings  for  the  poorest  of  the  poor. 
Many  of  the  lodgers  in  these  other  houses,  with  their  children, 
visited  the  room  where  the  woman  and  the  sick  child  resided.  By 
the  time  Dr.  Paterson  was  requested  by  the  magistrates  to  inspect 
the  tenement,  several  persons  were  already  dead  of  small-pox  caught 
from  this  imported  case.  One  man,  who  had  already  in  previous 
life  suffered  from  two  attacks  of  small-pox,  visited  the  infected 


548  PROPOSAL  TO  STAMP  OUT  SMALL-POX,  ETC. 

tenement,  and  sickened  and  died  of  a third  attack  of  the  malady. 
The  disease  soon  spread  to  other  parts  of  Leith ; and,  as  I am 
informed  by  the  registrar  of  that  town,  ninety-nine  human  beings 
were  destroyed  by  it,  and  much  suffering  and  sickness  produced 
among  the  many  hundreds  in  the  town  who  caught  the  disorder  and 
recovered.  But  if  that  first  case  or  cases  had  been  obliged  to  be 
reported  on  at  once,  and  had  been  forthwith  isolated  in  the  hospital 
or  elsewhere,  all  this  unnecessary  amount  of  human  mortality  and 
disease  would  have  been  avoided ; nor  would  the  isolation  and 
maintenance  of  the  first  case,  or  of  the  first  ten  or  twenty  cases, 
have  cost  as  much  money  as  the  purchase  of  the  coffins  for  the 
ninety-nine  who  died.  The  blowing-up  of  the  powder  magazine  in 
the  fort  at  Leith  would  not  likely  produce  nearly  so  much  danger 
and  destruction  of  life  among  the  inhabitants  of  Leith  as  the  advent 
of  the  beggar  woman  and  her  infected  child.  Yet  how  carefully  do 
we  guard  against  the  one  danger,  and  how  carelessly  do  we  treat 
the  other ! 

In  1818-19,  above  3000  individuals  were  attacked  with  small- 
pox in  Norwich,  or  about  a thirteenth  part  of  the  whole  population 
of  that  city.  Of  those  attacked,  530  died.  The  disease  was 
originally  introduced  into  the  town,  according  to  Mr.  Cross,  by  a 
girl  who,  in  travelling  with  her  parents  from  York  to  Norwich,  was 
exj^osed  to  small-pox  at  a market-town  in  the  course  of  her  journey; 
and  the  malady  appeared  on  her  as  soon  as  she  arrived  in  Norwich. 
This  was  in  June  1818.  In  January  1819,  a druggist  gave  a new 
impulse  to  the  contagion  by  inoculating  three  children  with  the 
small-pox.  The  disease  destroyed  in  Norwich,  according  to  Mr. 
Cross,  more  human  life  in  the  same  space  of  time  than  had  ever 
taken  place  from  any  other  cause  than  the  plague.  The  isolation  of 
the  girl  first  affected,  and  the  prevention  of  the  artificial  inoculation 
of  the  three  children  by  the  druggist,  would  have  prevented  all  this 
frightful  mortality.  To  inoculate  any  one  now-a-days  artifically  with 
small-pox — as  the  druggist  did — has  for  many  years  been  established 
by  Act  of  Parliament  as  a crime,  inasmuch  as  it  tends  to  imperil  the 
destruction  and  death  of  others.  Should  it  not  be  equally  regarded 
as  a crime  for  a community  to  allow  of  a case  in  their  midst  (such 
as  that  of  the  girl  first  affected  at  Norwich)  to  remain  in  circum- 
stances allowing  of  the  deliberate  dissemination  and  unchecked 
spread  of  the  disease  from  her  to  others  1 

My  friend  Dr.  Stark,  who  takes  such  diligent  superintendence 
of  the  death  registration  in  Scotland,  tells  me  that  constantly — as 


EARLY  NOTIFICATION. 


549 


in  these  cases  at  Leith  and  Norwich — he  hears,  through  his  official 
returns,  of  small-pox  spreading  in  districts  here  and  there  from  one 
imported  central  case. 

In  order  to  stamp  out  small-pox,  the  first  of  the  four  regulations 
which  I have  ventured  to  lay  down  (see  p.  545),  as  to  the  earliest 
possible  notification  of  the  presence  of  the  disease,  is  indispensably 
essential.  The  “ Public  Health  Act  ” for  Scotland  enacts  that  the 
keeper  of  any  common  lodging-house  shall,  when  any  of  its  inmates 
are  ill  of  fever,  or  of  any  infectious  disease,  “ give  immediate  notice 
thereof,”  either  to  the  medical  officer,  or  the  inspector  of  the  poor, 
or  the  inspector  of  lodging-houses,  in  order  that  the  medical  officer 
shall  forthwith  visit  and  report  on  the  case,  and  due  means  of  pre- 
vention be  taken  by  the  “ Local  Authorities.” 

It  would  surely  not  be  reckoned  too  hard  a measure  for  the 
public  safety  that  every  householder  should — by  himself  or  through 
his  medical  attendant — be  obligated  by  the  Legislature  to  report 
upon  the  existence  of  any  case  of  small-pox  that  might  appear  in 
his  establishment.  In  the  same  spirit,  every  medical  practitioner 
might  be  bound  to  report  immediately  any  example  of  the  disease 
that  he  met  with  in  practice.  All,  or  almost  all,  cases  of  small-pox 
could  thus  be  brought  under  official  notice  comparatively  early  in 
the  progress  of  the  malady.  As  the  disease  does  not  mature  into 
the  stage  of  infection  for  some  days  after  the  eruption  shows  itself, 
a free  period  would  thus  be  secured  for  arranging  proper  measures 
of  isolation,  either  at  home  or  in  hospital,  before  the  date  and 
danger  of  infection  were  reached. 

Further,  with  the  view  of  preventing  the  infection  of  others  by 
patients  that  have  passed  through  small-pox  or  its  perils,  it  will  ever 
be  a matter  of  importance  to  prohibit  and  prevent  the  possibility  of 
infecting  others  till  the  power  of  infection  is  exhausted.  Small-pox 
patients  have  apparently  the  power  of  dealing  out  the  disease  to 
others,  as  long  as  any  parts  of  the  incrustation  of  the  eruption  are 
left  on  their  faces,  hands,  or  body.  Until  that  time,  and  it  may  be 
a few  days  longer,  segregation  from  the  susceptible  is  necessary ; 
and  no  doubt  would  be  followed  by  every  person  of  proper  feeling, 
for  who  would  inflict,  or  run  the  chance  of  inflicting  disease  and 
death  on  his  fellow-beings  ? If  he  gives  the  infection  even  to  one 
individual  only,  from  that  individual  it  may  possibly  become  multi- 
plied and  propagated  to  hundreds.  And  before  mixing  again  in 
society,  the  persons  of  the  sick,  as  well  as  of  the  attendants,  should 


550  PROPOSAL  TO  STAMP  OUT  SMALL-POX,  ETC. 

perhaps — as  already  suggested — be  subjected  to  bathing  and  some 
systematised  disinfection.  Like  other  physicians,  I have  heard  of 
various  cases  of  small-pox  and  other  infectious  diseases  propagated 
from  the  sick  at  an  advanced  period  of  their  own  convalescence. 
Several  instances  have  been  communicated  to  me  of  beggars,  in  the 
streets  of  Edinburgh  and  elsewhere,  importuning  for  charity  by 
lifting  up  their  children,  with  small-pox  incrustations  still  upon 
them,  almost  against  the  very  faces  of  those  from  Avhom  they  asked 
alms,  and  infecting  with  the  malady  those  whom  they  subjected  to 
this  outrage.  Not  long  ago,  a woman — as  I am  informed  by  Pro- 
fessor Gairdner — with  her  face  and  hands  incrusted  with  small-pox, 
was  seen  selling  sweetmeats  to  the  children  of  a school  in  Glasgow. 
I have  heard  of  repeated  instances  of  small-pox  obtained  by  riding 
in  public  carriages,  which  had  been  employed  immediately  before 
by  persons  still  in  the  stage  of  convalescence  from  the  malady.  The 
Sanitary  Acts  of  England,  Scotland,  and  Ireland,  ought  in  a great 
measure  to  protect  the  lieges  against  such  abuses  for  the  future,  as 
they  forbid,  under  a penalty,  any  persons  suffering  from  infectious 
disorders  (as  small-pox,  hooping-cough,  etc.)  from  entering  a public 
conveyance,  or  wilfully  exposing  themselves  in  any  street  or  public 
place,  or  being  exposed  by  others  in  any  street  or  public  place, 
without  proper  precautions  against  spreading  the  disease.^ 

^ Other  infectious  diseases  are  often  spread  in  very  advanced  stages  of  con- 
valescence ; and  lives  are  constantly  destroyed  by  not  remembering  and  acting 
upon  this  all-important  fact.  I was  lately  told  of  a rich  merchant-prince  building 
himself  a palace  in  the  country.  Scarlet  fever  broke  out  in  the  family  of  one  of 
his  gatekeepers  shortly  after  he  took  up  his  residence.  A certain  amount  and 
length  of  separation  was  enforced,  hut  not  enough  ; for  at  last  one  of  the  gate- 
keeper’s children,  in  an  advanced  stage  of  convalescence  from  the  disease,  was 
allowed  to  come  to  him  and  deliver  a letter.  In  consequence  of  this  unfortunate 
communication  the  merchant  himself  sickened  and  died  of  the  scarlatina.  Some 
years  ago  I lost  a dear  friend  and  patient  of  measles,  which  broke  out  three  days 
after  her  accouchement.  She  had  come  thousands  of  miles  to  be  under  my  care. 
She  was  infected  thus  : — A girl  came  to  beg  at  the  door  of  her  country  residence, 
near  Edinburgh.  The  girl  stated  she  had  been  in  hospital  with  measles,  and  had 
been  dismissed  when  still  too  weak  to  work.  The  servant  who  conversed  with 
the  girl  took  measles,  and  gave  it  to  some  of  the  children.  I brought  my  patient 
herself  into  Edinburgh  as  soon  as  possible,  as  she  had  never  had  measles,  and  all 
the  eruptive  fevers  are,  it  is  well  knoAvn,  almost  always  fatal  when  they  attack 
the  puerperal  nfother.  But  it  was  too  late.  I wrote  her  husband  by  one  mail 
saying  she  Avas  quite  AA’ell,  but  I AA^as  in  great  fear  of  her  from  this  exposure.  For 
tAVo  days  after  delivery  she  AA'as  inclined  to  hold  all  the  precautionary  measures 
as  utterly  unnecessary ; but  the  third  day  the  fatal  disease  attacked  her,  and  I Avas 
obliged  to  Avrite  her  husband  by  the  next  mail  the  sad  news  of  her  death.  The 
neAv-born  child  took  measles,  but  recovered. 


EXPENSE  OF  STAMPING  OUT. 


551 


The  late  stamping-out  of  rinderpest  proved  a most  successful, 
but,  at  the  same  time,  a most  expensive  proceeding.  The  disease, 
and  the  poleaxe  as  a means  of  extirpating  it,  has,  I am  informed, 
cost  cattle-proprietors  and  the  country — in  the  price  of  the  animals 
destroyed — a sum  of  about  £2,000,000  sterling.  To  stamp  out 
small-pox  from  amongst  us,  and  thus  save  annually  hundreds  and 
thousands  of  human  lives  by  its  extirpation,  would  require  no  such 
sum  as  was  expended  on  the  extinction  of  the  cattle-disease,  and, 
indeed,  would  require  little  or  truly  no  outlay  beyond  what  the 
Legislature  has  already  enacted,  and  exacts  for  the  protection  of  the 
public  health ; for,  as  previously  stated,  much  of  the  machinery  for 
its  extirpation  already  exists  under  the  late  Sanitary  Acts  of  Great 
Britain  and  Ireland.  The  segregation  of  those  affected  with  small- 
pox who  belong  to  classes  which  are  able  to  keep  the  sick  member 
or  members  of  their  family  at  home,  would,  of  course,  cost  the 
country  nothing ; while  the  rules  applicable  to  their  isolation  could, 
if  faithfully  followed,  be  managed  without  any  special  inconvenience, 
or  any  injury  to  their  feelings ; and  generally,  if  not  always,  under 
the  superintendence  and  resj^onsibilty  of  their  own  medical  attend- 
ants. These  regulations  would  involve  no  restrictions  that  are  not 
followed  out  at  present  in  every  well-regulated  family  when  in- 
fectious disease  attacks  any  of  its  members ; none,  indeed,  except 
such  as  common  prudence  and  common  humanity  demand  for  the 
protection  of  the  bodies  and  lives  of  those  that  are  still  happily 
unaffected.  Any  open  breach  of  rules  that  tended  deliberately  to 
spread  the  disease,  and  endanger  and  destroy  the  health  and  lives 
of  others,  would  of  course  require  to  be  repressed  by  proper 
penalties.  The  primary  separation  and  the  mainUnance  of  the 
poorer  classes  under  the  circumstances  is  already  provided  for  under 
the  Sanitary  Acts and  our  present  sanitary  laws  are,  in  relation  to 
the  poorer  classes,  defective  in  their  powers  of  stamping  out  in- 
fectious diseases,  merely  and  mainly  in  as  far  as  they  do  not  enforce 
the  isolation  of  the  sick  by  due  cautions  after  they  are  lodged  in 
hospitals  or  in  houses  for  their  reception.  No  new  outlay  of  money 
would  require  to  be  legalised  ; but  even  if  required,  tlie  expenditure 
of  a few  thousand  pounds  would  surely  form  a small  imperial  pay- 
ment for  the  preservation,  yearly,  of  some  thousands  of  our  human 
population  from  death,  through  one  of  the  most  dreaded  and  loath- 
some of  human  diseases.  In  the  eye  of  the  political  economist  and 
of  the  philanthropist,  the  premature  slaughter  annually  of  three  or 
four  thousand,  or  even  of  three  or  four  hundred,  human  beings,  is  a 
loss  that  cannot  be  easily  estimated  by  mere  yellow  gold. 


552 


PROPOSAL  TO  STAMP  OUT  SMALL-POX,  ETC. 


The  measure  which  I have  suggested  would  probably,  in  my 
opinion,  stamp  out  small-pox  in  Great  Britain  within  six  months  or 
a year,  provided  they  were  carried  out  as  faithfully  and  universally 
as  the  Legislature  can  command  ; and  if  the  extirpation  of  the 
disease  were  thus  once  effected,  any  fatal  case  or  cases  of  the  return 
of  the  malady  to  any  seaport,  city,  town,  village,  or  country  district, 
would  be  speedily  notified  by  a machinery  already  in  full  operation 
— viz.  the  registration  of  deaths ; and  all  the  requisite  powers  for 
stamping  out  the  disease  in  the  newly  infected  locality  could  at  once 
be  set  in  full  operation.  All  our  sanitary  acts  provide  for  any 
instances  of  this  or  other  infectious  disease  when  introduced  into 
our  seaports  by  ships — ordering  the  removal  of  the  sick  to  an 
hospital  or  other  place  for  their  reception ; but  in  this  (as  in  the 
case  of  our  own  poor  in  these  same  hospitals  and  places),  totally  for- 
getting to  regulate  their  due  isolation,  so  that  they  may  not  heed- 
lessl}^  sow  and  scatter  round  them  the  seeds  of  disease  and  death. 

. Measures  of  quarantine  and  isolation,  similar  to  those  I have 
suggested  in  the  present  paper,  have  been  tried  elsewhere  in  the 
British  dominions,  and  found  to  answer.  At  the  various  ports  of 
South  Australia,  all  entrance  to  those  affected  and  capable  of  spread- 
ing small-pox  has  been  so  well  guarded  against,  that  in  only  one 
instance  — as  mentioned  to  me  by  Dr.  Grainger  Stewart — has  the 
disease  spread  landward  into  the  city  of  Melbourne,  in  consequence 
of  an  affected  individual  getting  into  the  town  through  the  misre- 
presentation of  the  captain  and  surgeon  of  the  ship  in  which  he 
arrived.  He  inflicted  the  disease  upon  nearly  twenty  of  the  resi- 
dents. The  authorities  then  interfered,  placed  all  the  affected  in  an 
inland  quarantine  station,  and  the  disease  spread  no  farther.  Thus 
the  malady  was  at  once  stamped  out.  A different  fate  a few  years 
ago  attended  the  introduction  of  measles  into  the  colony  of  Western 
Australia.  I am  informed  by  my  pupil,  Mr.  Page,  that  towards  the 
latter  end  of  the  year  lS62  the  disease  in  question  was  introduced 
by  some  persons  arriving  by  the  monthly  mail  steamer  which  touched 
at  King  George’s  Sound.  “ As  this,”  he  writes  me,  “ was  the  first 
attack  of  measles  that  had  visited  the  colony,  a large  proportion  of 
the  white  inhabitants  and  all  the  coloured  natives  had  never  before 
been  sulqect  to  its  influence.  The  disease  spread  with  such  rapidity 
and  fatality  that  the  coloured  population  in  the  settled  districts  was 
almost  swept  away  by  it,  a very  small  number  only  of  those  attacked 
recovering.  The  whites  also  suffered  severely,  many  children  and 


VARIOUS  DISEASES  CONSIDERED. 


553 


adults  dying,  but  the  ravages  of  the  disease  were  not  nearly  so  fright- 
ful amongst  them  as  amongst  the  coloured  natives.” 

In  conclusion,  I would  beg  to  make  one  remark.  That  formid- 
able quaternion  of  diseases — Small-pox,  Scarlatina,  Measles,  and 
Hooping-cough — kill  annually  in  Europe  above  half-a-million  of  its 
inhabitants,  and  particularly  of  the  younger  portion  of  its  popula- 
tion ; — carrying  sorrow  and  desolation  into  thousands  of  households. 
My  observations  in  the  present  communication  refer  especially  to 
the  stamping  out  of  small-pox,  for  I believe  it  is  the  malady  whose 
extirpation  could  thus  most  easily  be  effected.  But  the  same  prin- 
ciples apply,  and  will,  I believe,  be  applied  betimes  to  these  other 
analogous  diseases,  when  the  science  of  public  health  is  more  ad- 
vanced,— for  the  study  of  it  is  yet  in  its  infancy.  Scarlatina  and 
measles  will  become  greatly  reduced,  if  not  extirpated,  by  an  obser- 
vance of  similar  rules.  In  due  course  they  will  be  extended  to 
hooping-cough.  Typhus,  and  other  communicable  diseases,  will  also 
come  to  be  controlled  by  their  influence.^  I have  already,  at  the 
beginning  of  these  observations,  stated  that  during  the  ten  years 
from  18 5 G to  1866  above  51,000  individuals  had  died  of  small-pox 
in  Great  Britain  ; and,  if  we  calculate  approximately  from  the  popu- 
lation, above  12,000  more  in  Ireland,  or  upwards  of  60,000  in  the 
United  Kingdom.  In  the  ten  years  from  1856  onwards  (I  have  no 
later  data)  there  died  in  the  United  Kingdom  from  scarlatina  above 
280,000;  from  measles  above  130,000  ; and  from  hooping-cough 
above  150,000  ; or  about  600,000  of  our  population  were  killed  off 
by  these  four  diseases.  To  what  extent  can  this  terrible  decennial 
death-roll  be  shortened  or  abolished  by  the  process  of  isolation  and 
stamping  out  % Is  not  the  whole  subject  a grave  and  momentous 
question  both  for  legislators  and  physicians  1 

^ Dr.  Adamson  of  St.  Andrews  informs  me  that  some  time  ago  a patient,  carry- 
ing from  a distance  the  infection  of  typhus,  came  to  St.  Andrews  and  was  laid  up 
there  with  an  attack  of  the  fever.  From  this  primary  case  the  malady  spread  to 
others,  till  several  died,  and  a considerable  number  were  laid  up  wdth  the  affection, 
but  recovered.  The  advent  of  this  infected  individual  to  St.  Andrews  thus  killed 
and  maimed  about  as  many  of  its  inhabitants  as  were  killed  and  maimed  by  the 
late  “diabolical  explosion  ” of  the  barrel  of  gunpowder  or  nitro-glycerine  against 
the  wall  of  the  prison  at  Clerkenwell.  But  how  very  differently  are  these  two 
series  of  human  deaths  and  dangers  estimated — and  their  repetition  attempted  to 
be  guarded  against — by  the  police,  the  legislature,  and  the  public  ! 


INDEX 


ANESTHESIA. 


ACONITE  as  a local  ansesthetic,  262. 

Action  of  anaesthetics,  155. 

Administration  of  ether,  modes  of,  174  ; 
of  chloroform,  177  ; when  dangerous, 
181 ; modes  of,  in  midwifery,  201. 

Aldehyde  as  an  anaesthetic,  167 ; as  a local 
anaesthetic,  262. 

America,  first  anaesthetic  operations  in, 
25  ; claims  to  discovery  of  anaesthetics 
in,  35. 

Anaesthetic  agents — mechanical  means,  2 ; 
Indian  hemp,  3 ; mandragora,  5 ; list 
of  agents,  155 ; how  they  produce 
effects,  156  ; chloroform,  157  ; chloride 
of  hydrocarbon,  165  ; nitrate  of  ethyle, 
166  ; benzin,  166  ; aldehyde,  167  ; bi- 
sulphuret  of  carbon,  168  ; chlorocarbon, 
170. 

Ancient  history  of  anaesthesia,  1. 

Animals,  local  anaesthesia  in  lower,  256. 

Appleton,  Dr.,  on  ether,  23. 

Aurelianus  on  mandragora,  7. 

BENZIN  as  an  anaesthetic,  166. 

Bigelow,  Dr.  Henry,  on  ether,  32. 

Bigelow,  Dr.  Jacob,  Letters  to,  12,  18. 

Bisulphuret  of  carbon  as  an  anaesthetic, 
168  ; as  a local  anaesthetic,  262. 

Boccaccio’s  ‘Decameron,’  quoted,  9. 

Brotherston,  Dr.,  case  of  death  from  chlo- 
roform, 148. 

Burns,  Professor,  of  Glasgow,  on  anaes- 
thetic amputation,  107. 

CAMPBELL’S  ‘ Lives  of  the  Lord  Chan- 
cellors,’ quoted,  131. 

Carbon,  bisulphuret  of,  as  an  anaesthetic, 
168. 

Carbonic  acid  gas  as  an  anaesthetic,  2 ; 
as  a local  anaesthetic,  265,  276  ; in 
sedative  baths,  282  ; on  mucous  sur- 
face of  the  eye,  285  ; on  mucous 
surfaces  of  the  bladder,  285  ; on. 
mucous  surfaces  of  the  trachea  and 
lungs,  287  ; on  external  wounds  and 
burns,  287 ; carcinoma  relieved  by, 
282. 


Cases  illustrative  of  use  of  chloroform; 
183. 

Channing,  Dr.,  on  introduction  in  mid- 

' wifery,  34. 

Cheselden  on  operating,  80. 

Chloric  ether  as  an  amesthetic,  165. 

Chloride  of  hydrocarbon  as  an  anaesthetic, 
165. 

Chlorocarbon  as  an  anaesthetic,  170. 

Chloroform,  first  use,  25  ; as  anaesthetic, 
157  ; deaths  from,  143  ; Dr.  Brother- 
ston’s  case,  148  ; summary  of  deaths 
from,  151  ; summary  of  advantages  of, 
158 ; chemical  history,  160  ; inodes 
of  preparation,  161  ; physical  and 
chemical  properties,  161  ; therapeutic 
history,  161 ; physiological  effects,  161  ; 
uses  in  surgery,  162  ; uses  in  midwifery, 
162  ; uses  in  medicine,  162  ; cautions, 
163,  180  ; administration  of,  174  ; 
overdose,  treatment  of,  181  ; in  infant- 
ile convulsions,  etc.,  186;  in  peritonitis, 
189  ; in  pneumonia,  190  ; in  acute  in- 
flammation, 190  ; administration  of,  in 
midwifery,  201  ; rules  for  exhibition 
of,  in  labour,  206  ; in  natural  labour, 
207  ; in  morbid  labour,  210  ; as  a local 
antesthetic,  263,  269  ; taken  internally, 
274. 

Chomel,  Professor,  on  statistics,  103. 

Coal-gas  as  a local  amesthetic,  265. 

Collins,  Dr.,  Lying-in  Hospital  statistics, 
113. 

Convulsions,  etc.,  chloroform  in,  186. 

Copland,  Dr.,  on  parturient  jiain.  111. 

Cow-pox  inoculation,  69. 

Curling,  Mr.,  on  ether,  107. 

DANGER  from  anaesthesia,  113-143. 

Davy,  Sir  Humphry,  on  nitrous  oxide, 
1,  29. 

Deaths  from  chloroform,  143  : summary 
of,  151. 

Defences.  (See  Objections.) 

Dioscorides  on  mandragora,  6. 

Drugs,  anaisthesia  by  swallowing  of,  3. 

Dutch  liquid  as  an  amesthetic,  165. 


556 


INDEX. 


ELLIS,  Dr.,  on  ether,  34. 

Ethyle,  nitrate  of,  as  an  anaesthetic,  168. 

FORCEPS,  use  of,  on  anaesthetised  patient, 
118, 

Frost,  Eben.,  case  of,  27,  31. 

GREAM  on  anaesthetic  agents,  138. 

HAMILTON,  Professor,  on  labour  pain, 
126. 

Hardy,  Dr.,  on  anaesthetic  douche,  269. 

Hickman,  Dr,,  on  carbonic  acid,  2. 

Hindoo  suttee,  3. 

History  of  anaesthesia,  ancient,  1 ; ancient, 
in  midwifery,  10;  modern,  13;  mo- 
dern, in  midwifery,  31  ; of  local  anaes- 
thesia, 253. 

Hooping-cough,  chloroform  in,  189. 

Howgrave,  Mr.,  on  small-pox,  76, 

Hydrocarbon,  chloride  of,  as  an  anaesthetic, 
165. 

INDECENCIES,  alleged,  in  anaesthesia, 
138. 

Indian  hemp  as  an  anaesthetic,  3 ; as  a 
local  anaesthetic,  262. 

Iodide  of  methyle  as  a local  anaesthetic, 
262. 

JACKSON,  Dr.,  on  nitrous  oxide,  29. 

Jefferson’s  memoirs,  quoted,  127. 

Jocelyn,  life  of  St.  Kentigern  quoted,  10. 

KEEP’S,  Dr,,  case,  34. 

King  of  Poland,  case  of,  3. 

LABOUR,  anaesthesia  in  natural,  207  ; 
morbid,  210. 

Lawrie,  Dr.,  of  Glasgow,  on  results  of 
amputation,  99. 

Lebrun,  Claude,  on  anaesthesia  by  crimi- 
nals, 7, 

‘ Les  Screes  ’ quoted  on  memphitis,  9. 

Letheby,  Dr.,  on  chloroform,  142. 

Lipscomb  on  small-pox,  68. 

Liston,  Mr.,  on  ether,  106. 

Local  anaesthesia,  history,  253  ; in  ani- 
mals, 256  ; in  man,  260  ; general  re- 
sults, 261 ; aldehyde,  etc.,  as  local  anaes- 
thetics, 262  ; summary  regarding,  268  ; 
chloroform  as  a local  anaesthetic,  263, 
269 ; carbonic  acid  as  a local  anaesthetic, 
265,  276. 

MAGENDIE,  M.,  on  etherisation,  82. 

Malgaigne,  Professor,  on  statistics  of  am- 
putation, 99. 

Man,  local  anaesthesia  in,  260. 

Mandragora,  5. 

Mechanical  means,  anaesthesia  by,  2. 

Medicinc,ap])licationsof  anmsthesiain,  186. 


Meigs,  Professor,  answer  to  objections  of, 
117. 

Merriman,  Dr.,  again.st  anaesthesia,  110. 

Middleton  on  anaesthesia,  10. 

lilidwifery,  history  of  anaesthesia  in,  10, 
31  ; defences  of  anaesthesia  in,  108  ; 
superinduction,  141  ; applications  of 
ether  in,  192  ; first  use  of  ether  in, 
193 ; rules  for  chloroform  in,  206  ; 
cases,  207  ; mode  of  exhibiting  chloro- 
form in,  201  ; reports  on,  214  ; results 
of  the  practice  of  anaesthesia  in,  245. 

Miller,  Professor,  on  etherisation,  52. 

Modern  history  of  anaesthesia,  12. 

Montague,  Lady  Mary  Wortley,  71. 

Moore,  Dr.,  proposal  of,  2. 

Morton’s,  Dr.,  volume  quoted,  27,  28,  29, 
30,  31,  34,  39. 

Moseley,  Dr.,  on  cow-pox,  68. 

NAEGELE,  Professor,  oji  natural  labour, 

112. 

Nature  of  anaesthetics,  154. 

Nepenthe,  4. 

Nitrous  oxide  first  used,  25 ; used  by  Wells, 
29. 

OBJECTIONS  to,  42  ; religious,  42  ; pre- 
judices, 65  ; prevention  of  pain  unneces- 
sary, 75  ; as  increasing  mortality,  93  ; 
moral,  109  ; danger,  113,  143  ; in  mid- 
wifery, 108, 117  ; sensation  of  patient  a 
guide,  117  ; pain  a safeguard,  121, 128, 
132  ; indecencies,  138  ; difficulty  of 
superinduction,  141  ; occasional  fatal 
results,  143. 

Opinions  of  practitioners,  214. 

Opium,  deaths  from,  as  defence  of  anaes- 
thesia, 114  ; as  a local  anaesthetic,  262. 

Overdose,  treatment  of,  181. 

PAIN  from  a patient’s  point  of  view, 

86. 

Pain,  in  surgery,  75,  86,  107  ; in  labour, 
117. 

Pare,  Ambrose,  on  pain,  83. 

Peritonitis,  chloroform  in,  191. 

Pliny  on  mandragora,  6. 

Pneumonia,  chloroform  in,  189. 

Porta,  Baptista,  on  mandragora,  7. 

Prejudices  answered,  65. 

RAYNALDE  on  midwiferjq  114. 

Reid,  Dr.  James,  on  anaesthesia,  140. 

Religious  objections  answered,  42. 

Results  of  anaesthesia  in  midwifery,  re- 
ports of,  214;  on  children,  245  ; on 
mothers,  246. 

Rigby,  Dr.,  on  jnidwifery,  112. 

Rowley,  Dr.,  on  cow-pox,  68,  77. 


SAINT  GERAN,  Countess  of,  case,  11. 


INDEX. 


557 


Scythians,  use  of  anaesthetics  hy,  4, 

Sedative  baths,  carbonic  acid  in,  282. 

Sensajtions  under,  199. 

Shakespeare  on  anaesthetics,  8. 

Smith,  Protheroe,  Dr.,  letter  to,  56. 

Squin-ell,  Dr.,  on  cow-pox,  77. 

Statistical  tables — anaesthetic  agents,  154  ; 
amputations  under  anaesthesia,  96,  97, 
102  ; without  anaesthesia,  98-102  ; com- 
parison of  amputations  with  and  with- 
out, 103-107. 

Statistics  of  surgical  operations  with  and 
without  anaesthesia,  93,  et  seq. 

Sulphuric  ether  first  used  for  anaesthesia, 
25  ; administration,  174  ; first  case  in 
midwifery,  193. 

Superinduction,  alleged  difficulties  of, 

141. 

Surgery,  history  of  anaesthesia  in,  1,  12  ; 
alleged  unnecessary,  75  ; effects  on  mor- 


tality, 93  ; conditions  to  ensure,  175  ; 
cases,  183. 

TABLES.  (See  Statistical.) 

Taylor’s  ‘ Medical  Jurisinnulence  ’ quoted, 
131. 

Theocritus  on  nodynia,  10. 
Tooth-extraction,  anaesthesia  for,  27. 
Travers,  Mr.,  on  pain,  83. 

UTERUS,  contractions  of,  121. 

VACCINATION,  as  illustration,  51,  66, 

77. 

WELLS,  Dr.,  claims  of,  28,  et  seq. 

Wood  and  Bache  on  ether,  23. 

YVER,  Jacques,  on  mandragora,  9. 


HOSPITALISM. 


AGED,  amputations  on,  308,  353. 

Aggregation,  percentage  death-rate  ac- 
cording to,  340,  356. 

Air  in  surgical  wards,  383. 

Alteration  of  hospitals,  400. 

BALDING,  Mr.,  remarks  of,  ,316. 

Beds,  amputations  in  hospitals  under  300, 
S93  ; 200,  394  ; 100,  395  ; 25,  397. 

Boyd,  Dr.,  remarks  of,  314. 

CADE,  Mr.,  remarks  of,  315. 

Causes  of  death,  differences  of,  377. 

Causes  of  death  after  amputations,  310, 
378  ; forearm  amputation,  350. 

Comparison  of  country  and  large  hospital 
amputations,  338. 

Country  amputations  — statistics,  288  ; 
double  amputations,  305  ; injuries,  etc., 
necessitating,  309  ; causes  of  death  in, 
310  ; class  of  patients  in,  313  ; severity 
of  cases  recovering  in,  317. 

Country  operators,  success  of,  347. 

Cribbe,  Mr.,  remarks  of,  314. 

DOUBLE  amputations,  306,  353. 

EDINBURGH  Infirmary,  amputations  in, 
330. 

Erichsen,  Professor,  remarks  of,  317. 

Experience,  success  in  country  amputa- 
tion in  proportion  to,  346. 

FOREARM  amputations,  comparison  of, 
349. 

Foreign  statistics,  327. 


GIRVAN,  Mr.,  remarks  of,  315. 

Glasgow  Infirmar}'',  amputations  in,  331. 
Guy’s,  amimtations  in,  334. 

HAMILTON,  Dr.,  remarks  of,  317. 
Healthy,  deaths  of,  in  ho.spitals,  388. 
Holmes,  Mr.,  objections  of — 

I.  Data  too  few,  357. 

II.  Length  of  time  in  returns,  358. 

HI.  Things  eompared  di.ssimilar,  359. 

IV.  Comparison  unfair,  360. 

V.  Cases  selected,  366. 

VI.  Hopeful  cases  withdrawn  from  hos- 
pitals, 367. 

VII.  Comparison  delusive,  368. 

VIII.  Private  cases  should  be  collected, 
370. 

Hospital  and  country  amputations,  39, 
305. 

IRVINE,  Dr.,  remarks  of,  316. 

Isolation,  death-rate  according  to,  340, 
356. 

JEFFRAA’,  Dr.,  remarks  of,  315. 

LINDSAY,  Dr.,  remarks  of,  315. 

London,  hospital  amputations  in,  333. 
Lying-in  hospital  mortality,  346. 

METROPOLITAN  hospitals,  amputa- 
tions in,  9,  336. 

OBJECTIONS.  See  Holmes. 

Opinions  of  comparative  success  in  country 
1 hospitals,  322. 


558 


INDEX. 


PATIENTS,  condition  of,  373. 

Percentage  difference,  success  in  hospitals 
and  country,  347. 

Primary  amputations,  comparative  severity 
of,  374. 

Propositions  on  Hospitalism — 

I.  On  isolation  regulating  results, 
340. 

II.  On  differences  in  death-rate  not 
explained  by  nature  of  in- 
juries, etc.,  342. 

III.  On  comparative  fatality  of  limb- 

amputations,  344. 

IV.  On  increased  success  in  country  in 

pi’oportion  to  experience,  346. 

V.  On  comparison  of  single  ampu- 
tations, 347. 

VI.  On  greater  contrast  in  simpler 
operations,  348. 

VII.  On  amputation  of  forearm,  348. 

VIII.  On  causes  of  deaths  from  forearm- 
amputations,  350. 

IX.  On  double  amputations,  353. 

X.  On  amputations  on  aged  persons, 
353. 

XI.  On  differences  in  death-rates 
being  enormous,  etc.,  359. 

XII.  That  country  amputations  should 
be  more  dangerous,  372. 

XIII.  On  state  of  the  patients,  373. 

XIV.  On  comparative  severity  of  prim- 

ary amputations,  374. 

XV.  That  more  comparatively  die  of 
shock  in  country,  375. 

XVI.  On  comparative  danger  of  thigh- 
amputations  for  disease,  376. 

XVII.  On  differences  of  causes  of  death, 
377. 

XVIII.  On  causes  of  death,  Mr.  Holmes’ 
points,  etc.,  378. 

XIX.  On  pyaemia  by  inoculation, 
382. 

XX.  On  air  in  surgical  wards,  383. 

XXI.  On  deaths  in  hospitals  of  the 
healthy,  388. 

Provincial  hospital  amputations,  390,  99. 
Pyaemia  by  inoculation,  382. 

ST.  BARTHOLOMEW’S,  amputations  in, 
332. 

St.  George’s,  amputations  in,  335. 
Schedule  for  country  amputations,  293. 
Severity  of  cases  in  country  amputations, 
317. 

Shock,  deaths  from,  375. 

Simple  operations,  comparative  success  of, 
348. 


Size  of  hospitals  regulating  mortality,  399. 
Statistics  of — 2098  country  amputations, 
305  ; 2089  hospital  amputations,  305  ; 
3077  provincial  hospital  amputations, 
390. 

Statistical  Tables — 

I.  Countiy  amputations,  296-304. 

II.  Double  amputations,  306. 

III.  Amputations  on  patients  over  70 

yeai’s  old,  308. 

IV.  Larger  amputations  in  Edinburgh 

Infirmary,  330. 

V.  Larger  amputations  in  Glasgow 
Infirmary,  331. 

VI.  Larger  amputations  in  St.  Bar- 
tholomew’s, 332.  • 

VII.  Larger  amputations  in  London 
Hospital,  333. 

VIII.  Larger  amputations  in*  Guy’s 
Hospital,  334. 

IX.  Largeramputations  in  St.  George’s 
Hospital,  335. 

X.  Larger  amputations  in  9 London 

Hospitals,  336. 

XI.  Larger  amputations  in  11  large 

hospitals,  337. 

XII.  Proportionate  death-rate  accord- 
ing to  isolation,  340. 

XIII.  Proportionate  death-rate  in 

liosjutals,  341. 

XIV.  Cottage  and  lying-in  hospital 

mortality,  345. 

XV.  Rural  and  large  hospital  mortality, 
346. 

XVI.  Comparative  success  of  different 
country  operators,  347. 

XVII.  Difference  of  percentages,  347. 
XVIII.  Country  and  city  amputations  in 
major  operations,  348. 

XIX.  Comparison  of  forearm  amputa- 
tions, 349. 

XX.  Percentage  of  death-rate  according 
to  isolation*  356. 

XXI.  Causes  of  death  after  amputation, 
378. 

XXII.  Amputations  in  hospitals  of  201 
to  300  beds,  393. 

XXIII.  Amputations  in  hospitals  of  101 
to  200  beds,  394. 

XXIV.  Amputations  in  hospitals  of  26  to 
100  beds,  395. 

XXV.  Amputations  in  hospitals  of  25 
beds  and  under,  397. 

Stewart,  Dr.,  remarks  of,  314. 

TABLES.  See  Statistical. 
Thigh-amputations,  376. 


INDEX. 


559 


HERMAPHRODITISM. 


ADHESION  of  penis,  422. 

Arsaiio,  M.  E.,  case  of,  451. 

BIBLIOGRAPHY,  540. 

Birds,  true  lateral  in,  436. 

Bouillaud’s  case,  456. 

CASTRATION,  influence  of,  487. 

Causes  of,  532  ; indirect  influence  of  tes- 
tes, 533  ; errors  in  development,  534  ; 
hereditary  predispositions,  535  ; ques- 
tions of  twin  births,  536. 

Classification,  409. 

Clitoris,  abnormal  development  of,  410. 

Clitoris  large  in  animals,  499. 

Conformation  of  the  body — hermaphro- 
ditism in,  479. 

Corpora  Wolfliana,  homology  of,  502. 

DEFINITION  of,  408. 

Double  monsters,  538  ; sex  of,  539. 

Double,  or  vertical  true,  453  ; vesicula 
seniinales  added  to  female  organs,  459  ; 
imperfect  uterus  added  to  male  organisa- 
tion, 460  ; co-existence  of  ovaries  and 
testes,  470. 

Duplicity  of  organs,  515  ; alleged  primi- 
tive, 517. 

Durge,  Charles,  case  of,  443. 

EMBRYONIC  TYPE,  persistence  of,  525. 

Eschricht’s  case,  454. 

Extroversion  of  bladder,  421. 

FALLACIES  about  hermaphroditism,  519  ; 
in  judging  of  addition  of  male  seminal 
ducts  to  female  organs,  521  ; of  female 
uterus  and  male  organs  co-existing,  522  ; 
co-existence  of  testicles  and  ovaries,  527. 

GAERTNER’S  ducts,  errors  from,  521. 

HARLAN’S,  Dr.,  case,  475. 

Homology  of  male  and  female  organs,  510. 

Hypospadias,  422  ; in  animals,  431  ; 
hereditary,  535. 

INSECTS,  true  lateral  in,  434. 

KNOX,  Dr.,  theory  of,  517. 

LATERAL,  true,  434  ; in  insects,  434  ; 
in  birds,  436  ; in  mammals,  438  ; in 
man,  439  ; ovary  on  left,  testicle  on 
right,  439  ; testicle  on  left,  ovary  on 
right,  445. 


Lateral  in  secondary  sexual  characters, 
492. 

Lefort,  M.  M.,  case  of,  416. 

MALAUSE,  Marguerite,  case  of,  419. 

Mammals,  true  lateral  in,  438. 

Man,  true  lateral  in,  439. 

Maret’s  case,  445. 

Mayer’s  cases,  443,  461,  457. 

NONZIA,  Maria,  case  of,  429. 

OTTO’S  case  of  hypospadias,  428. 

PLUMAGE  of  male  birds  on  female, 
485. 

Pregnancy  in,  529. 

Prolapsus  of  uterus,  419. 

Pro-ovarium,  homology  of,  505. 

Prostate  gland,  etc.,  liomology  of,  509. 

RAMSBOTHAM’S,  Dr.,  case,  414. 

Rosenmuller’s  organ,  homology  of,  502. 

Rudolphi’s  case,  440. 

SECONDARY  sexual  characters,  481  ; 
conclusions  regarding,  491. 

Self-impregnation,  question  of,  531. 

Spurious  in  female,  410  ; from  abnormal 
development  of  clitoris,  410  ; from  pro- 
lapsus of  uterus,  419. 

Spurious,  in  male,  421  ; from  extroversion 
of  bladder,  421  ; fi-oni  adhesion  of 
penis  to  scrotum,  422  ; from  hypo- 
spadias, 422. 

Spurious,  general  summary  regarding,  496. 

Steghlehner’s  cases,  450,  465. 

Sue’s,  M.,  case,  439. 

TESTICLES  and  ovaries,  co-existence  of, 
527. 

Transverse,  true,  447  ; with  external  fe- 
male type,  447  ; in  animals,  448  ; in 
man,  450 ; with  external  male  type, 
453. 

True,  432.  (See  “ lateral,”  “ transverse,” 
and  “double.”) 

UNITY  of  sexual  type,  500. 

Uterus,  male,  errors  from,  523  ; homology 
of,  507. 

VAROLE’S  case,  440. 

Viragines,  483. 


560 


INDEX. 


PROPOSAL  TO  STAMP 

Australia,  isolation  in,  552,  measles  in, 
552. 

Continuance,  causes  of,  544. 

Enforcing  of  isolation,  546. 

Expense  of  stamping  out,  548,  551. 
Isolation  among  the  rich,  551  ; poor,  551. 
Late  infection,  avoidance  of,  549. 

Leith  case,  547. 


OUT  SMALL-POX,  ETC. 

Mortality  from  smallpox,  543. 

Norwich  case,  548. 

Other  diseases,  stamping  out  of,  553. 
Propagation,  modes  of,  543. 

Rinderpest,  stamping  out  of,  544  ; isola* 
tion  for,  545  ; Sanitary  Act,  545. 

Time  of  infection,  549;  to  stamp  out 
552. 


INDEX  TO  THE  ORIGINAL  SOURCES  OF 


Chap.  I. 
Chap.  II. 

Chap.  III. 


Chap.  I. 
Chap.  II. 


Chap.  III. 
Chap.  IV. 
Chap.  V. 

Chap.  VI. 
Chap.  VII. 
Chap.  VIII, 
Chap.  IX. 
Chap,  X. 
Chap.  XI. 


Chap.  I. 
Chap.  II. 

Chap.  III. 
Chap.  IV. 


Chap.  I. 


THE  CONTENTS. 


ANJiSTIlESIA. 

Part  I. 

Compiled  from  Lecture  Notes. 

Letter  to  Dr.  Jacob  Bigelow,  Boston,  published  by  Edmonston  and 
Douglas,  Edinburgh,  1870. 

Do.  do.  do. 

Part  1 1. 

Published  by  Sutherland  and  Knox,  Edinburgh,  December  1847. 
Letter  to  Dr.  Protheroe  Smith,  London.  See  Appendix  to  Scriptural 
Authority  for  the  Mitigation  of  the  Pains  of  Labour.  S.  Highley 
and  Co.,  London. 

From  Edin.  Monthly  Journal  of  Medical  Science,  Sept.  1847. 

From  Do.  do.  Sept.  1847. 

A Letter  from  Dr.  George  Wilson,  published  in  Obstetric  Memoirs 
and  Contributions,  A.  and  C.  Black,  Edinburgh,  1856. 

From  Edin.  Monthly  Journal  of  Medical  Science,  April  1848. 

From  Do.  do.  Oct.  1848. 

From  Association  Medical  Journal,  July  1853. 

From  Proceedings  of  Obstetrical  Society,  14th  February  1849. 

From  Edinburgh  Monthly  Journal  of  Medical  Science,  October  1848. 
Letter  to  Editor  of  Medical  Times  and  Gazette,  19th  June  1852. 
From  article  “Chloroform,”  Encyclopoedia  Britannica,  vol.  vi.  1855. 
From  Medicad  Times  and  Gazette,  23d  February  1870. 

Part  III. 

Compiled  from  Lecture  Notes. 

Communicated  to  Edinburgh  Chirurgical  Societ}^ 

From  Edin.  Monthly  Journal  of  Medical  Science,  Dec.  1847. 

From  Do.  do.  April  1848. 

From  Medical  Times  and  Gazette,  December  1865. 

Part  IV. 

From  Edin.  Monthly  Journal  of  Medical  Science,  Sept.  1847. 

From  Do.  do.  Jan.  1848. 

From  Author’s  Obstetric  Memoirs  and  Contributions.  A.  and  C. 
Black,  Edinburgh,  1856. 

From  Proceedings  of  Obstetrical  Society,  14th  Nov.  1860,  Edin. 
Monthly  Journal  of  Medical  Science,  Dec.  1861. 


562 


INDEX  TO  THE  OEIGINAL  SOURCES. 


Chap.  I.  From  article  “ Chloroform,  ” E'acyclopcedia  Britannica,  vol.  vi. 
Compiled  from  Lecture  Notes. 

Chap.  II.  Communicated  to  Edinburgh  Medical  Chirurgical  Society. 

Chap.  III.  From  Edinburgh  Monthly  Journal  of  Medical  Science,  January  1852. 
From  Proceedings  of  Obstetrical  Society,  29th  July  1863. 

Part  V. 

Chap.  I.  From  Edinburgh  Monthly  Journal  of  Medical  Science,  March  1847. 

Communicated  to  Edinburgh  Medical  Chirurgical  Society. 

Chap.  II.  From  Edinburgh  Monthly  Journal  of  Medical  Science,  October  1848. 
Compiled  from  Lecture  Notes. 

Chap.  III.  Communicated  to  Edinburgh  Medical  Chirurgical  Society. 

Chap.  IV.  From  Edin.  Monthly  Journal  of  Medical  Science,  October  1848. 
Chap.  V.  From  Do.  do.  do. 

Part  VI. 

Chap.  I.  From  Provincial  Medical  and  Surgical  Journal,  July  1848. 

Chap.  1 1.  From  Do.  do.  do. 

Chap.  III.  From  Do.  do.  do. 

Chap.  IV.  From  Lancet  and  Medical  Association  Journal,  July  1848. 

Chap.  V.  Addressed  to  the  New  York  Academy  of  Medicine. 

Chap.  VI.  From  Dublin  Medical  Press,  April  1858. 


HOSPITALISM. 

Chap.  I.  From  Edinburgh  Monthly  Journal  of  Medical  Science  for  March  1869. 
Chap.  IT.  From  Do.  do.  for  June  1869. 

Chap.  III.  From  the  Lancet  for  Aug.  28,  Sept.  4,  Sept.  25,  Oct.  2,  Oct.  16,  1869. 
Chap.  IV.  From  Do.  for  Nov.  20,  1869. 

Chap.  V.  From  Edinburgh  Monthly  Journal  of  Medical  Science,  Dec.  1869. 
Chap.  VI.  From  the  Lancet  for  19th  Nov.  1870  (prepared  for  the  Press  by  Mr. 
Lawson  Tait). 


HERMAPHRODITISM. 

From  the  Cyclopccdia  of  Anatomy  and  Physiology,  1839. 


PROPOSAL  TO  STAMP  OUT  SMALL-POX,  etc. 
From  the  Medical  Times  and  Gazette  of  4th  and  11th  January  1868. 


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to  the  interrogation  of  the  mind,  he  shows  conclusively  that  self-consciousness-^the 
favorite  resort  of  the  schoolmen — is  inadequate,  contradictory,  and  unreliable.  No 
book  of  the  present  day,  devoted  to  the  study  of  the  mind,  has  attracted  more  atten- 
tion or  caused  more  comment  than  this.  It  is  one  of  those  works  which  mark  the 
beginning  of  a new  era  in  the  study  of  mental  science,  and  at  the  same  time  it  is 
conceded  on  all  sides  to  be,  in  its  practical  portions,  a most  reliable  guide  for  the 
diagnosis,  description,  and  treatment  of  insanity. 

“Dr.  Maiulslcy  has  had  the  courage  to  undertake,  and  the  skill  to  execute,  what  is,  at 
least,  in  En^dish,  an  original  enterprise.  This  book  is  a manual  of  mental  science  in  all  its 
parts,  embracing  all  tliat  is  known  in  the  existing  state  of  physiology.  * * * Many  aiid 
valuable  books  have  been  written  l)y  English  physicians  oh  insanity,  idiocy,  and  all  the 
forms  of  mental  aberration.  But  derangement  had  always  been  treated  as  a distinct  subject, 
and  therefore  empirically.  That  the  phenomena  of  sound  and  unsound  minds  are  not  mat- 
ters of  distinct  investigation,  but  inseparable  parts  of  one  and  the  same  inquiry,  seems  a 
truism  as  soon  as  stated.  But  stramre  to  say,  they  had  always  been  pursued  separately,  and 
been  in  the  hands  of  two  distinct  classes  of  investigators.  The  logicians  and  metaphysicians 
occasionally  borrowed  a stray  fact  from  the  abundant  cases  compiled  by  the  medical  author- 
ities; l)ut  the  physician  on  the  other  hand  had  no  theoretical  clew  to  his  observations  be- 
yond a smattering  of  dogmatic  psycholo;:v  learned  at  college.  To  effect  a reconciliation  be- 
tween tlie  Psychology  and  the  Pathology  of  the  mind,  or  rather  to  construct  a basis  for  both 
in  a common  science,  is  the  aim  of  Dr.  Maudsley's  XwolC'— London  Sat.  liev..  May  25, 1867. 

“The  first  chapter  is  devoted  to  the  consideration  of  the  causes  of  insanity.  It  would  be 
well,  we  think,  if  this  chapter  were  pnblislntd  in  a separate  form  and  scattered  broadcast 
throughout  the  land.  It  is  so  full  of  sensible  reflections  and  sound  truths,  that  their  wide 
dissemination  could  not  but  be  of  benefit  to  all  thinking  persons.  In  taking  leave  of  Dr. 
Maudsley's  volume,  we  desire  again  to  express  our  graiificaiion  with  the  result  of  his  labors, 
and  to  express  the  hope  that  he  has  not  yet  ceased  his  studies  in  the  important  field  which 
he  has  selected.  Our  thanks  are  also  due  to  the  American  publishers  for  the  very  handsome 
manner  in  which  they  have  reprinted  a work  which  is  certain  to  do  credit  to  a house  already 
noted  for  its  valuable  publications.”— Journal  of  Psychological  Medicine  and  Medical 
Jurisprudence. 

“Then  follow  chapters  on  the  diagnosis,  prognosis,  and  treatment  of  insanity,  each 
characteri/.cd  by  the  same  bold  and  brilliant  thought,  the  same  charming  style  of  composi- 
tion, and  the  same  sterling  sense  that  we  have  found  all  through.  We  lay  dowm  the  book 
with  admiration,  and  we  commend  it  most  earnestly  to  our  readers,  as  a work  of  extraordi- 
nary merit  and  originality — one  of  those  productions  that  are  evolved  only  occasionally  in 
the  lai)se  of  years,  and  that  serve  to  mark  actual  and  very  decided  advances  in  knowledge 
and  science,”— W.  Y.  Medical  Journal.,  January.,  1868. 

“ This  work  of  Dr.  Maudsley’s  is  unquestionably  one  of  the  ablest  and  most  important, 
on  the  subjects  of  which  it  treats,  that  has  ever  appeared,  and  does  infinite  credit  to  his 
philosophical  acumen  and  accurate  observation.  No  one  has  more  successfully  exiiibiled  the 
discordant  results  of  metaphysical,  physiidogical,' and  patholoirical  studies  of  the  mind,  or 
demonstrated  more  satisfactorily  the  uselessness  of  an  exclusive  method,  or  the  pressing 
need  of  combined  action,  and  of  a more  philosophical  mode  of  proceeding.”— 

Record.  Nov.  15,  1867. 

“In  the  recital  of  the  causes  of  insanity,  as  found  in  peculiarities  of  civilization,  of  relig- 
ion, sex,  condition,  and  particularly  in  the  engrossing  pursuit  of  wealth,  this  calm  scientific 
work  has  the  solemnity  of  a hundred  sermons  : and  after  going  down  into  this  exploration 
of  the  mysteries  of  our  being,  we  shall  come  up  into  active  life  again  chastened,  thonghtfal, 
and  feeling,  perhaps,  as  w'e  never  felt  before,  how  fearfu«Ily  and  wonderfully  we  are  made.” — 
Evening  Gazelle. 

“Dr.  Maudsley’s  treatise  is  a valuable  work,  and  deserves  the  carehil  consideration  otau 
who  feel  an  interest,  not  only  in  general  metaphysical  facts,  btit  in  those  manifestationa 
wliich  mark  the  boundaries  between  health  ami  disease  in  the  human  mind.”— 

(A.  1.)  Jou  rnal. 


D.  AITLETON  & CO.'S  MEDICAL  PUBLICATIONS. 


Flint’s  Physiology. 

The  Physiology  of  Man^  designed  to  represent  the  existing  State  oj 
Physiological  Science  as  applied  to  the  Functions  of  the  Human 
Body.  By  Austin  Flint,  Jr.,  M.  D.,  Prof*,  of  Physiology 
and  Microscopy  in  the  Bellevue  Hospital  Medical  College, 
Fellow  of  the  New  York  Academy  of  Medicine,  etc.,  etc. 

Vol.  I.  Introduction.  The  Blood  ; Circulation  ; Respiration.  8vo. 

Cloth  (tinted  paper). $4.50. 

Vol.  II.  Alimentation ; Digestion ; Absorption ; Lymph,  and  Chyle. 

Cloth  (tinted  paper). $4.50. 

“ Before  the  issue  of  the  first  part  we  entertained  the  opinion  in  common  with  others  that 
there  was  no  room  for  a text-book  on  physiolo^^y,  and  that  a physician  of  his  (Ur.  F.’s)learu- 
intf  and  acquirements  could  more  advantageously  employ  his  time  in  experimental  research 
than  in  writing  a systematic  treatise.  Dr.  Flint  has  convineed  us  that  we  were  mistaken,  lu 
this  view.  We  accept  tlie  two  volumes  already  issued  as  evidence  of  what  we  may  exnect 
in  the  remaining  part  of  the  series.  We  regard  them  as  the  very  best  treatises  on  human 
physiology  which  the  English  or  any  other  language  affords,  and  we  recommend  them  with 
thorough  confidence  to  students,  practitioners,  and  laymen,  as  models  of  literary  and  scien- 
tific ability.”— W.  Y.  Medical  Journal,  Oct.,  1807. 

“The  treatise  of  Dr.  Flint  is  as  yet  incomplete,  the  first  two  volumes  only  having  been 
published;  but  if  the  remaining  portions  are  compiled— for  every  physiological  work  em- 
bracing the  whole  subject  must  be  in  a great  measure  a compilation— with  t!ie  same  care  and 
accuracy,  the  whole  may  vie  with  any  of  those  that  have  of  late  years  been  produced  in  our 
own  or  in  foreign  languages.”— iJnYis/i  and  Foreign  Medico- Chirurgical  Revie  w. 

“ The  second  of  the  scries  has  just  been  published,  and  is  now  before  us.  It  treats  of  the 
great  function  of  Nutrition  under  the  several  heads  of  Alimentation,  Digestion,  Absorption, 
the  Lymph,  and  Chyle.  Upon  these  topics  the  author  bestows  the  same  judicious  care  and 
labor  which  so  eminently  characterize  the  first  volume.  Facts  are  selected  with  discrimina- 
tion, theories  critically  examined,  and  conclusions  enunciated  with  commendable  clearness 
and  precision.”— America/!  Journal  of  the  Medical  Sciences. 

“Judging  from  the  able  manner  in  which  this  volume  is  written,  the  series,  when  per- 
fected. will  be  one  of  those  publications  without  which  no  library  is  complete.  As  a book 
of  general  information,  it  will  be  found  useful  to  the  practitioner,  and  as  a book  of  reference, 
invaluable  in  the  hands  of  the  anatomist  and  physiologist.” — Dublin  (Quarterly  Journal  oj 
Medical  Scic/icc. 

“The  work  is  calculated  to  attract  other  than  professional  readers,  and  is  written  with 
sufficient  clearness  and  freedom  from  technical  pedantry  to  be  perfectly  intelligible  to  any 
well-informed  man.”— Zoaefon.  Saturday  Review. 

“From  the  extent  of  the  author’s  investigations  into  the  best  theory  and  practice  of  the 
present  day  the  world  over,  and  the  candor  and  good  judgment  which  he  brings  to  bear  upon 
the  discussion  of  each  subject,  we  are  justified  in  regarding  his  treatises  as  standard  and 
authoritative,  so  far  as  in  this  disputed  subject  authority  is  admissible.”— A^.  Y.  Times. 

“ The  complete  work,  judging  from  the  present  instalment,  will  prove  a valuable  addition 
to  our  systematic  treatises  on  human  physiology.  The  volume  before  us  is  executed  wilh 
conscientious  care,  and  the  style  is  readable  and  clear.  It  is  a volume  which  will  be  wel- 
come to  the  advanced  student,  and  as  a work  of  reference.”- Lancet. 

“These  excellent  monographs  offer  the  most  complete  summary  of  the  physiologio.al 
knowledge  of  our  day  yet  written  in  America,  They  are  brought  down  to  the  most  recent 
advances  of  the  science,  and  include  the  results  of  a number  of  original  expenments.”-- 
Philadelphia  Medical  Reporter. 

“The  leading  subjects  treated  of  are  presented  in  distinct  parts,  each  of  which  is  de- 
signed to  be  an  oxhaustive  essay  on  that  to  which  it  refers.” — Western  Journal  of  Medicine. 

“ The  interesting  feature  of  the  -work  is  a recital  of  typical  experiments,  which  are  timely 
and  judiciously  introduced  to  impress  the  facts  upon  the  mind  of  the  reader.  It  is  printed 
in  elegant  style,  and  may  be  considered  a model  in  the  typographical  line.”  -Med.  Record. 

“We  have  found  the  style  easy,  lucid,  and.  at  the  same  time,  terse.  The  practical  and 
positive  results  of  physiological  investigation  are  succinctly  stated,  without,  it  would  seem, 
extended  discussion  of  disputed  points.”  — Zosto/i  Medical  'and  Surgical  Journal. 

“^To  those  who  desire  to  get  a concise,  clear,  but  at  the  same  time  sufficiently  full  re- 
sume of  the  existing  state  of  physiological  science,  we  heartily  recommend  Dr.  Flint's  work. 
Moreover,  as  a work  of  typographical  art,  it  deserves  a prominent  place  upon  our  library 
shelves.”— J/erfica^  Gazette,  N.  Y. 


n.  APPLETON  & CO:S  MEDICAL  PUBLICATIONS. 


Elliot’s  Obstetric  Clinic. 

A Practical  Contribution  to  the  Study  of  Obstetrics  and  the  Dis- 
eases of  Women  and  Children.  By  George  T.  Elliot,  Jr., 
A.  M.,  M.  D.,  Prof,  of  Obstetrics  and  the  Diseases  of  Women 
and  Children  in  the  Bellevue  Hospital  Medical  College,  Physi- 
cian to  Bellevue  Hospital  and  to  the  New  York  Lying-in  Hos- 
pital, etc.,  etc.  8vo,  pp.  458.  . . Cloth,  $4.50 

This  volume,  by  Dr.  Elliot,  is  based  upon  a large  experience,  including  fourteen 
years  of  service  in  the  lying-in  department  of  Bellevue  Hospital  of  this  city.  The 
book  has  attracted  marked  attention,  and  has  elicited  from  the  medical  press,  both 
of  this  country  and  Europe,  the  most  flattering  commendations.  It  is  justly  be- 
lieved that  the  work  is  one  of  the  most  valuable  contributions  to  obstetric  literature 
that  has  appeared  for  many  years,  and,  being  eminently  practical  in  its  character, 
cannot  fail  to  be  of  great  service  to  obstetricians. 

“ The  volume  by  Dr.  Elliot  has  scarcely  less  value,  althouirh  in  a different  direction,  than 
that  of  the  Edinbunrh  physician  (Dr.  Duncan,  Researches  in  Obstetrics).  The  materials  com- 
prising it  have  been  principally  gathered  through  a service  of  fourteen  years  in  the  Bellevue 
Hospital,  New  York,  during  the  whole  of  which  time  the  author  has  been  emraged  in  clini- 
cal teacliiug.  The  cases  now  collected  into  a handsome  volume  illustrate  faithfully  the  anx- 
ieties and  disappointments,  as  well  as  the  fatigues  and  successes,  which  are  inseparable 
from  the  responsible  practice  of  obstetrics— a line  of  practice  which,  under  difficulties,  de- 
mands the  greatest  moral  courage,  the  highest  skill,  and  the  power  (ff  acting  promptly  on  a 
sudden  emergency.  Dr.  Elliot’s  favorite  subject  appears  to  be  operative  midwifery;  but 
the  chapters  on  the  relations  of  albuminuria  to  pregnancy,  ante-partum  haemorrhage,  the  in- 
duction of  labor,  and  the  dangers  which  arise  from  compression  of  the  funis,  are  all  deserving 
of  careful  perusal.  The  pleasure  we  feel  at  being  able  to  speak  so  favorably  of  Dr.  Elliot’s 
volume  is  enhanced  by  the  circumstance  that  he  was  a pupil  at  the  Dublin  Lying-in  Hospital 
when  Dr.  Shekeltou  was  master.  We  can  certainly  say  that  his  teachings  reflect  great  credit 
upon  his  Alma  ’Sla.iev."— London  Lancet.,  April  11,  1868. 

“ This  may  be  said  to  belong  to  a class  of  books  ‘ after  the  practitioner’s  own  heart.’  In 
them  he  finds  a wider  range  of  cases  than  comes  under  his  observation  in  ordinary  practice  ; 
in  them  he  learns  the  application  of  the  most  recent  improvements  of  his  art;  in  them  he 
finds  the  counterpart  of  cases  which  have  caused  him  the  deepest  anxiety  ; in  them,  too,  he 
may  find  consolation,  for  the  regret— the  offspring  of  limited  experience,  which  has  always 
cast  a shadow  on  the  remembrance  of  some  of  his  fatal  cases— will  pass  away  as  he  reads  of 
similar  ones  in  which  far  greater  resources  of  every  kind  failed  to  avert  Ji  fatal  termination. 

“ There  are  not  many  books  of  this  kind  in  our  language ; they  can  probably  all  be  num- 
bered on  the  fingers  of  a sin.;le  hand.  * * * Many  circumstances  concur,  therefore,  to  influ- 
ence us  to  extend  to  this  work  a cheerful  welcome,  and  to  commend  it  as  fully  as  possible. 
We  do  thus  welcome  it ; as  the  production  of  a gentleman  of  great  experience,  acknowledged 
ability,  and  high  position— as  an  emanation  from  one  of  the  leading  schools  of  our  country, 
and  as  an  honorable  addition  to  our  national  medical  literature.”— A we/’/can  Journal  of 
Medical  Science.,  April,  1868. 

“As  the  book  now  stands,  it  is  invaluable  for  the  practitioner  of  obstetrics,  fi)r  he  will 
h.ardly  ever  in  practice  find  himself  in  a tight  place,  the  counterpart  of  which  he  will  not 
find  in  Dr.  Elliot’s  book.”— Aett;  YorTc  Medical  Journal.,  February,  1868. 

“The  book  has  the  freshness  of  hospital  practice  throughout,  in  reference  to  diagnosis, 
pathology,  therapeutical  and  operative  proceedings.  It  will  be  found  to  possess  a great 
amount  of  valuable  information  in  the  department  of  obstetrics,  in  an  attractive  and  easy 
style,  according  to  the  most  modern  and  improved  views  of  the  profession.” — Cincinnati 
Lancet  and  Observer,  April,  1868. 

“As  a whole,  we  know  of  no  similar  work  which  has  issued  from  the  .American  press, 
which  can  be  compared  with  it.  It  ought  to  be  in  the  hands  of  every  practitioner  of  mid 
wifery  in  the  country.” — Boston  Medical  and  Surgical  Journal. 

“One  of  the  most  attractive  as  well  as  forcibly  instructive  works  we  have  had  the 

Eleasure  of  reading.  In  conclusion,  we  recommend  it  as  one  having  no  equal  in  the  English 
mguage,  as  regards  clinical  instruction  in  obstetrics.”— Am.  Jour,  of  Obstetrics,  Aug..  1868. 
Many  ripe,  elderly  practitioners  might,  but  few  young  could,  write  a book  so  distin- 
guished by  candor,  want  of  prejudice,  kindly  feeling,  soundness  of  judgment,  and  extent  of 
erudition.  While  we  do  not  say  the  book  is  faultless,  we  say  there  is  no  book  in  American 
obstetrical  literature  that  surpasses  this  one.  * * * * The  work  now  under  review  is 
his  first-born  book  or  volume,  and  shows  how  fine  opportunities  he  has  had,  chiefly  at  Belle- 
vue Hospital,  for  acquiring  experience,  and  how  diligently  he  has  availed  himself  of  them. 
But  his  book  shows  much  more.  It  is  the  work  of  a physician  of  high  education,  a qualifi- 
cation in  which  jbstetric  authors  are  often  deficient— it  shows  qualities  of  mind  and  skill 
of  haud  rarely  attained  by  so  young  a man.” — Edinburgh  Medical  Journal,  Feb.,  1.%S. 


